HAYNEVILLE TELEPHONE COMPANY, INC. SERVICES APPLICATION

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1 HAYNEVILLE TELEPHONE COMPANY, INC. SERVICES APPLICATION SELLER SUBSCRIBER Hayneville Telephone Company, Inc. (HTC) P.O. Box 175 Hayneville, AL Telephone: Fax: Name: Address: E911 Address: City, State, & Zip: Tel. Number: This Application, along with the HTC Customer Service Agreement, HTC s Tariff, Price List, Fair Access Policy, Acceptable Use Policy, Cable TV Subscriber Privacy Policy and any other referenced HTC Document, shall become part of a binding contract with you upon its acceptance by HTC. 1. RECURRING MONTHLY SERVICES: When appropriate, please make your selection by initialing below. (You may choose only one.) You agree to pay full price for the services selected below unless you subscribe to a promotion or special offer. All prices and terms are subject to change, as provided in the HTC Customer Service Agreement and applicable Price Lists. Basic Local Exchange Service and Optional Features: Residential Business Gordonsville: $16.30 $32.60 (1 pty) $44.60 (key, multi-line, trunk) Hayneville: $16.30 $32.60 (1 pty) $44.60 (key, multi-line, trunk) Lowndesboro: $16.30 $32.60 (1 pty) $44.60 (key, multi-line, trunk) HTC TELEPHONE BUNDLES: Basic Bundle: $41.95 (Local service, Unlimited Lata wide, Unlimited LD) Basic Plus Bundle: $55.95 (Local, Unlimited LATA wide, 5 calling features, Unlimited LD) Advantage Bundle: $76.95 (Local, LATA wide, DSL 1.5, 5 calling features, Unlimited LD) Elite Bundle: $91.95 (Local, LATA wide, DSL 1.5, 5 calling features, Unlimited LD) Max Bundle: $ (Local, LATA wide, Unlimited LD, 5 calling features, DSL 3.0) Third Party Block Remove Third Party Block Collect Block Remove Collect Block 1+ Block Remove 1+ Block 0+ Block Remove 0+ Block Toll Restrict with PIN Remove toll Restrict with PIN Area Calling Service Block Remove Area Calling Service Block ALL 900 SERVICE IS BLOCKED BY HTC. I request that this block be lifted. I will pay for all 900 calls on my telephone number. Remove 800 Block. I request the 800 block be lifted. I understand that I am fully responsible for any such calls on my bill. Custom Calling Services Any 4 Features (except Call Transfer and Speed-30) $6.00 $8.00 All Features (except Call Transfer and Speed-30) $8.00 $10.00 Any 3 Features and 2 Local Area Signaling Services $10.00 $11.00 (except Caller Name and Number Delivery and Caller ID/Call Waiting Deluxe) $ Custom Local Area Signaling Services $ Any 4 Features (except Caller Name and Number $8.50 $9.00 Delivery and Caller ID/Call Waiting Deluxe) All Features $12.00 $12.50 Lifeline Assistance: $13.50 monthly credit Link-Up: Up to $30.00 credit on service connection charge Page 1 of 5

2 By applying, Customer declares that he/she is eligible for such assistance by virtue of participation in one of the following programs: Medicaid, Food Stamps, Section 8 Federal Public Housing Assistance (FPHA), Supplemental Security Income (SSI), Low Income Home Energy Assistance Program (LIHEAP) and Temporary Assistance for Needy Families (TANF) by me, a dependant who lives in customer s household or another resident of the household for which the customer is financially responsible. Proof of eligibility may be required. I would like to have a Local Service Freeze on my account so that no local provider can change my local telephone service from HTC without my knowledge. Yes No Long Distance Services (provided by Hayneville Long Distance): Hometown Advantage: $0.09 per minute national rate; No monthly fee Hometown Advantage Plus: $0.055 per minute national rate; $4.95 per month Hometown Business 800 Advantage: $ per minute rate based on usage; $3.00 per month ($10.00 installation) Hometown Advantage Personal 800 Service: $0.35 per minute national rate; No monthly fee Freeze my long distance carrier. I have chosen for my InterLATA and IntraLATA long distance carrier. This means that I must dial before I dial any number outside the HTC exchanges, except those designated as free calls, and no long distance company can change my carrier without my knowledge. Broadband Services*: DSL Lite: DSL 1.5 Mbps: DSL 3 Mbps: Dial Up: $19.95 Residential only (Up to 512k Bandwidth); requires a modem $34.95 Residential; requires a modem $46.95 Business; requires a modem $46.95 Residential; requires a modem $58.95 Business; requires a modem $14.95 Residential and Business *Broadband Services offered to the subscriber include Broadband access, Internet access, Modem, & News Services and 24/7 Tech Support provided via , as well as other services as specified. Modems may be purchased from HTC for $ Standard installation charge for DSL is $ (DSL and High Speed Wireless Equipment, if leased, shall at all times remain the property of HTC.) Customers must meet the following operational requirements in order to use the Broadband Services: Processor: Pentium 133 or higher. Power PC for Mac. Operating System: Windows NT 4.0 or higher or Mac OS 8.0 or higher. System Memory RAM: 32 MB or more of physical RAM. Hard Disk Space: 60 MB Minimum available for Application and Windows NT. Modem: 28.8 Kpbs or higher for Dial-up. CD Rom Drive: Any speed. DSL: NT-Functioning Network Adapter; Windows 2000 or later (required for DSL 3.0); XP-Functioning Network Adapter or available USB Port. Will you purchase or lease the modem? User ID: 4-19 characters, can contain a mix of letters, numbers and symbols spaces and slashes) Your address will be your User Password: 4-19 characters, can contain a mix of letters, numbers and symbols spaces and slashes) Please note that your Password is case sensitive. Telephone Number: Do you currently have telephone service with another telephone provider? If so, what number?. If yes, you must complete the LOA Information Section of this form. Do you have Internet with your current provider? Yes / No Additional contact number: Page 2 of 5

3 Unlisted number: Your telephone number will not be given out to anyone, even in an emergency. Your telephone number, name and address may be disclosed in connection with E911 service, whether provided by HTC or any other person. By subscribing to an unlisted number, you waive any privacy interests in such a disclosure in connection with E911 service. Do you want to be listed in the directory? yes no (There is a $2.00 monthly charge for nonpublished/private numbers.) If you would like your number listed, under what name or names? (An additional charge applies for secondary listing.) LOA INFORMATION: I, (the Customer) hereby request Hayneville Telephone Company to be my local exchange carrier. I fully understand that HTC has an absolute and unencumbered right to act on my behalf with local exchange carriers, long distance carriers and other telecommunications companies regarding my local exchange services. I also authorize HTC to obtain credit and other information necessary to evaluate and process this agreement. I authorize HTC to switch my local exchange service from my current local exchange carrier to HTC. I further authorize HTC to acquire copies of my customer service records and other account information from my current local exchange carrier in order to verify local exchange service and to place change orders with my current carrier. This Letter Of Agency rescinds all local exchange carrier letters of agency previously executed. Authorized Customer Signature: Date: List All Phone Numbers Associated With Account (Note: This should include distinctive or ringmaster numbers) CPNI INFORMATION: Hayneville Telephone Company, Inc. has always guarded our Customers private information with complete confidentiality and will continue to do so. We consider this one of our highest priorities. HTC has made the following changes to further protect your account information due to recent changes in Federal Communications Commission ( FCC ) rules about Customer Proprietary Network Information ( CPNI ). WHO MAY ACCESS YOUR ACCOUNT INFORMATION Only you, as the subscriber of record on the account, or persons specifically authorized by you in writing, will be able to access or discuss your account information and call records. If no additional authorized persons are added to the account, ONLY you will be able to obtain this information from HTC. In addition, before any of your account information may be discussed or disclosed, you or an authorized person must identify yourself to HTC representatives by providing a valid photo ID or password. KNOWING YOUR PASSWORD, CREATING A SHARED SECRET, and ADDING AUTHORIZED PERSONS TO YOUR ACCOUNT Please choose and enter your new account password in the space listed below and keep this password in a secure place. You will need this password to access or discuss your account information and call records with any HTC representative by phone. Your authorized person(s) will also need this password to discuss any information with a HTC representative by phone or in person. You also need to create a shared secret that will be used to change your password or access account information in case you forget your password. You may choose from the shared secret questions below simply by filling in one of the answer blanks. Finally, if you desire for anyone other than you to access your detailed account information, you must add them as an authorized person to your account by filling out the appropriate section below. This includes your spouse or anyone else. PLEASE SELECT A PASSWORD FOR YOUR ACCOUNT: SHARED SECRET and ANSWER: (Fill in only one blank below) AUTHORIZED PERSON(s) QUESTION Your Favorite Food Your Team Mascot ANSWER Page 3 of 5

4 I have read and understand the new account information listed on this form and hereby designate the person(s) I have listed above to have full access privileges to my private account information and call records. 2. NONRECURRING FEE(S) AND DEPOSIT(S): Deposit: $ DSL INSTALLATION CHARGE: $49.95 (One time Standard Installation Charge shall apply when subscriber line INITIALIZATION has begun, unless waived with certain promotions as specified.) Additional charges may apply to Non-Standard Installations for any service offered by HTC. Installation Charges may be waived with certain promotions, as specified. 3. DISCOUNTS OR TERMS ESTIMATED MONTHLY RECURRING CHARGES Services Quantity Unit Price Total Total Estimated Monthly Recurring Charges: Total does not include all applicable taxes, surcharges, E-911 fees or prorated charges. Term Customer and Service Provider Commitment, Beginning HTC Representative Date Authorized Customer Signature Date 4. TERMINATION AND MODIFICATION CHARGES: EARLY TERMINATION FEES AND REINSTATEMENT OF INSTALLATION CHARGES APPLY ONLY TO THOSE SERVICES UNDER A CUSTOMER SERVICE AGREEMENT WITH A FIXED TERM. TERMINATION OF YOUR SERVICE FOR ANY REASON, OTHER THAN CANCELLATION OF YOUR SERVICE BY HTC WITHOUT CAUSE, WILL REQUIRE YOU TO IMMEDIATELY PAY ANY AND ALL OUTSTANDING CHARGES, AS WELL AS A TERMINATION FEE IN AN AMOUNT EQUAL TO 100% OF THE UNPAID BALANCE FOR ALL SERVICES SCHEDULED TO BE PROVIDED UNDER THE AGREEMENT FOR THE REMAINDER OF THE TERM, INCLUDING, BUT NOT LIMITED TO, DEDICATED ACCESS FEES AND ANY INSTALLATION CHARGES PREVIOUSLY WAIVED BY HTC AS PART OF YOUR AGREEMENT. SUCH INSTALLATION CHARGES WILL BE ASSESSED AT HTC S PREVAILING RATES AT THE TIME OF TERMINATION OF THE AGREEMENT. IF YOU SEEK TO RESTORE YOUR SERVICE, YOU WILL ALSO BE SUBJECT TO THE TERMS OF A NEW AGREEMENT, WHICH MAY INCLUDE PAYMENT OF A NEW INSTALLATION CHARGE AND ANY ADDITIONAL CHARGES ASSOCIATED WITH INSTALLATION OR RECONNECTION OF YOUR SERVICE. YOU MAY CHANGE THE SERVICES PROVIDED UNDER YOUR AGREEMENT PRIOR TO THE END OF THE CONTRACT TERM WITHOUT INCURRING TERMINATION CHARGES OR REINSTATING INSTALLATION CHARGES; HOWEVER, IF THE NEW MONTHLY RECURRING CHARGES DO NOT MEET OR EXCEED THE MONTHLY RECURRING CHARGES UNDER YOUR CURRENT AGREEMENT, YOU WILL OWE A SERVICE REDUCTION FEE IN AN AMOUNT EQUAL TO THE DIFFERENCE IN THE MONTHLY CHARGES FOR THE REMAINDER OF YOUR CURRENT CONTRACT TERM. IF YOU SEEK TO RELOCATE YOUR SERVICE TO ANOTHER LOCATION WITHIN OUR SERVICE AREA, YOU WILL NOT BE SUBJECT TO EARLY TERMINATION FEES IF YOU TRANSFER ALL YOUR CURRENT SERVICES TO YOUR NEW LOCATION AND MAINTAIN THOSE SERVICES FOR THE DURATION OF THE TERM, BUT YOU WILL STILL BE RESPONSIBLE FOR ANY INSTALLATION CHARGES THAT ARISE FROM THE RELOCATION. 5. ADDITIONAL SERVICES AND FEES: Reconnection Fee: $ : $ Page 4 of 5

5 Termination Fee: $ : $ LIMITED WARRANTY: See HTC Customer Service Agreement. HTC makes no warranty on equipment. ADDITIONAL TERMS AND CONDITIONS: See HTC Customer Service Agreement, HTC s Tariff, Price List, Acceptable Use Policy and Fair Access Policy. A further description of the telephone service offerings referenced above can be found at and subsequent URLs. POLICY: By signing below, you also acknowledge notice of, accept and agree to all the terms and conditions included in the HTC Customer Service Agreement, and, any other applicable HTC documents, including, but not limited to, HTC s Tariff, Price Lists, Acceptable Use Policy, and Fair Access Policy, copies of which are posted at and policies and regulations which may be referenced therein, all of which are incorporated herein by reference and made a part hereof. Subscriber Acceptance BY SIGNING BELOW, YOU REPRESENT THAT YOU POSSESS THE AUTHORITY TO SIGN ON BEHALF OF THE SUBSCRIBER AND BIND SUBSCRIBER TO THIS AGREEMENT. SUBSCRIBER UNDERSTANDS AND AGREES TO BE BOUND BY THE AGREEMENT, INCLUDING, WITHOUT LIMITATION, HTC S CUSTOMER SERVICE AGREEMENT AND ALL APPLICABLE TERMS AND CONDITIONS OF SERVICE.. SUBSCRIBER AUTHORIZES HTC TO OBTAIN BILLING INFORMATION AND SUBSCRIBER SERVICE REPORTS WITH RESPECT TO SUBSCRIBER S TELEPHONE NUMBERS, AS WELL AS SUBSCRIBER S CREDIT INFORMATION. THIS AGREEMENT IS ACCEPTED BY HTC ON THE DATE INDICATED NEXT TO ITS SIGNATURE BELOW. Subscriber Signature Subscriber Name (Printed) Title (Printed) Date Authorized HTC Representative s Signature Authorized HTC Representative s Name (Printed) Title (Printed) Date Page 5 of 5

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