COMPANY INFORMATION

Company Name: *

Company Contact Phone Number: *

Company Contact: *

Email Address: *

Company Address: *

Company City: *

Company State: *

Company Zip Code: *

DESCRIPTION OF LOCATION

Section: *

Township: *

Range: *

City: *

County: *

HCE Reference:

HCE Reference:

THE WORK INDICATED BELOW HAS BEEN AGREED UPON BY YOUR Construction Supervisor AND the Holy Cross Contract Services Analyst

SKETCH: Upload the required Sketch: *
ATTACH SHEETS FOR THE LAYOUT OF POLES. O = Poles Owned By Holy Cross Energy x = Poles Owned By ___________________________

BILLING INFORMATION

Will attach to pole(s) on Rental Basis (Quantity): *

Will vacate pole(s) (Quantity): *

Wil purchase vacate(s) (Quantity): *

NET increase or decrease in attachments: *

REMARKS SECTION

Date: *

ELECTRONIC SIGNATURE OF APPLICANT (By typing in your name, you are agreeing to the terms of this Agreement.) *

Right click your mouse to print yourself a copy before you hit SUBMIT

*

In the box below, please type in the letters as they appear above.