MINES PARK HOUSING
CSM TELECOMMUNICATIONS
TELEPHONE SERVICES REQUEST FORM



NAME (Please Print) _______________________________________________________________



Last Name

First Name

STUDENT ID# ___________________________________________________________________

CAMPUS STREET ADDRESS_______________________________________________________

MINES PARK UNIT # __________________PHONE #__________________________________






ASSIGNED BY TELECOMMUNICATIONS



TELEPHONE SERVICE:

I WOULD LIKE TO REQUEST PHONE SERVICE.
I understand that I will pay $18.50 per month in base charges for this service. I hereby authorize
the CSM Telecommunications office to assess my Student account for these charges. Charges
are assessed in arrears each month.



LONG DISTANCE:

I WOULD LIKE TO SUBSCRIBE TO THE CSM LONG DISTANCE SERVICE.
I understand that by activating my code I assume responsibility for the use of my code and all
long distance charges initiated from this code. I hereby authorize the CSM Telecommunications
office to assess my Student account monthly.
YOU WILL NEED TO BRING THIS FORM TO THE TELECOMMUNICATIONS OFFICE TO GET
YOUR AUTHORIZATION CODE.

Telecommunications use only - Authorization code assigned _______________________

SAFEGUARD YOUR CODE AT ALL TIMES!

STUDENTS ARE RESPONSIBLE FOR ALL CHARGES UNTIL A DISCONNECT / CHECK-OUT SHEET HAS BEEN
FILLED OUT AND DELIVERED TO TELECOMMUNICATIONS.

____________________________________________________
__________________________________
STUDENT SIGNATURE




DATE

CSM Academic Computing & Networking
Telecommunications Office
1650 Arapahoe Street (CTLM Building, Rm 256, NE Corner)

Phone: 303-273-3122 (local) or 1-800-446-9488
Web site: http://www.mines.edu/academic/computer/telecom/student-serv.shtml