WP E-Signature by Approve Me - Sign Documents Using WordPress -

CUSTOMER CPNI REQUEST FORM

Lakeland Communications
825 Innovation Ave.
P.O. Box 40
Milltown, WI 54858
715-825-2171

Due to FCC mandated regulations, our customers’ proprietary information will be restricted, which safeguards our customers’ accounts while providing protection to the customer and to Lakeland. Customer Proprietary Network Information (CPNI) includes things like, but not limited to: current charges and services, balances and payments, calling patterns, usage, etc. Please fill out the information below and return to our office.

Account #:

Account Holders name:

Date of birth:

Service Address:

Billing Address (if different):

Telephone Number:

Email Address:

CPNI Password (4-16 alpha or numberic characters):

Recovery Password Questions

Mothers maiden name:

Name of first pet:

These people may obtain CPNI from my account (if desired):

Date:

Note: Lakeland Communications may call your telephone number of record once this form is received to verify the accuracy of this request.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

September 25, 2025 9:23 am CST

CUSTOMER CPNI REQUEST FORM Uploaded by Lakeland Communications - info@lakelandteam.com IP 67.164.15.7

September 25, 2025 9:54 am CST

Kayla Pilz - kaylap@lakelandteam.com added by Lakeland Communications - info@lakelandteam.com as a CC'd Recipient Ip: 73.70.70.181

September 25, 2025 10:11 am CST

Kayla Pilz - kaylap@lakelandteam.com added by Lakeland Communications - info@lakelandteam.com as a CC'd Recipient Ip: 73.70.70.181

September 25, 2025 10:13 am CST

Kayla Pilz - kaylap@lakelandteam.com added by Lakeland Communications - info@lakelandteam.com as a CC'd Recipient Ip: 73.70.70.181

September 26, 2025 9:42 am CST