MASCO Services, Inc. - Service Information Form

MASCO SERVICES INC., TELECOMMUNICATIONS OPERATIONS
A MASCO Group Company 375 Longwood Avenue, Boston, Massachusetts 02215-5328 617 632-2349 FAX: 617 732-2774

How were you referred to us?
Account Name
Street
City	State	Zip

Number of Clients associated with this account

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Name Home telephone #

Pager # Cell/Alt #

Type of business:
Answering Service Requested on Main Telephone Number
Fax Machine Number Office Hours
Point of Contact: Name Telephone # Pager #
Other Affiliations: Name Telephone # Pager #
Emergency Contacts: Name Telephone # Pager #
Emergency Contacts: Name Telephone # Pager #
Pager Information Alpha Numeric Tone Only
Pager Vendor Arch UCOM Skytel
Other, please specify:

Answering Service for:

Please specify emergency call procedures:

Do we page or call the home telephone number with calls at night?
Requested Service Date
Signature (entering your name will qualify as your signature) Date

If you have any questions regarding this form, please call 617-632-2349.

© 1998-2007 MASCO Services Inc.
Telecommunications & Customer Care Services
395 Longwood Avenue • Boston, MA 02215
Phone: (800) 690-7243 / Fax: (617) 632-2774