Welcome to Central Texas Telephone Cooperative!

Transcription

1 Welcome to Central Texas Telephone Cooperative! We are excited you have chosen to live in rural Texas! Our Cooperative is dedicated to providing you with the very best in telecommunications. Please print out this packet of information and complete the forms in full. Once completed, you may either mail the forms or fax them back to us. However, if you choose to fax them, we will need the original completed application forms along with any funds required prior to installation/activation. If you have any questions, please call our Customer Service Office at or Once again, we welcome you and look forward to you being a part of Central Texas Telephone Cooperative! We are here to serve you! Sincerely, CENTRAL TEXAS TELEPHONE COOPERATIVE, INC.

2 PO Box 627 Goldthwaite, TX (325) or (800) Please complete and return with an estimated installation / name change fee of $ Have you had service with our Cooperative before? Type of Service you are requesting: APPLICATION FOR MEMBERSHIP AND TELEPHONE SERVICE If yes, under what telephone number? t Venture Business Name (if applicable) Business Tax ID # (Required) If tax exempt, from which of the following? (An applicable exemption certificate must be provided for each) Individual Account Name (Member) Billing Address Social Security # Driver s License # Contact Address Is a joint membership between husband and wife sought? Spouse Name (Required if applying for joint membership) Spouse Social Security # Spouse Driver s License # Spouse Contact FEATURES Custom Calling Features Monthly Monthly Class Features Monthly Residential Business Automatic Call Back $2.00 Touch Tone (Required) * $1.25 $1.25 Automatic Recall $2.00 Anonymous Call Rejection $1.00 Call Waiting/Cancel Call Waiting $1.50 $2.00 Anonymous Call Rejection (when purchasing Caller ID) $0.50 Call Forwarding $1.50 $2.00 Selective Distinctive Ringing/Call Waiting $ Way Calling $1.75 $2.75 Selective Call Acceptance $2.00 Selective Call Rejection $2.00 Speed Dialing 8# $1.75 $2.75 Selective Call Forward $2.00 Speed Dialing 30# * $2.75 $3.75 Call Forward No Answer $1.50 Call Forward Busy $1.50 If purchased in a package: Call Forward Busy and No Answer $ Features $2.50 $3.50 Remote Call Forward $ Features $3.75 $5.00 Caller ID Number Delivery * $ Features $4.75 $6.00 Caller ID Name Delivery * $3.50 * Not included in Package Offerings Caller ID Name & Number Delivery * $6.50 Call Waiting ID (Caller ID feature required) * $1.50 Call Trace - each successful trace activation * $8.00 Optional Services Extended Local Calling (Please inquire into availability and pricing) Monthly Help Line $1.00 Help Line (when subscribing to any other feature excluding Touch Tone) $0.75 Inside Wire Maintenance (approval required) $1.50 Voice Mail - Residential $3.95 Voice Mail - Business $7.95 Additional Mailboxes for Residential or Business $1.00 Please indicate quantity If purchased in a package: * Not included in Package Offerings 2 Features $ Features $ Features $5.00 Optional Blocking Services Monthly Monthly Residential Business Toll Block Collect Calls Free Free Toll Block 3 rd Number Calls Free Free Toll Control w/ PIN $2.00 $2.00 Toll Block 1+ and 0+ Calls $1.75 $2.25 Toll Block 900 & 976 calls $0.00 $0.00 (A non-recurring service charge will apply to 900 & 976 changes made after initial application request) Office use only: Rev Membership # Telephone # New Member Applicant Date Received Amount $ Existing Member/Membership Conversion Cash Check # Credit Card

3 APPLICATION FOR MEMBERSHIP AND TELEPHONE SERVICE, PAGE 2 LONG DISTANCE CARRIER PLEASE SELECT THE LONG DISTANCE CARRIER OF YOUR CHOICE Please see the attached list and select your IntraLATA and InterLATA long distance carrier. I choose as my IntraLATA long distance carrier. I choose as my InterLATA long distance carrier. Signature Date DIRECTORY INFORMATION List in Directory as: Directory Address (911 Address or PO Box only No City Listed) Extra Directory Listings ($.25 residence, $.50 business Per Month) List in Directory as: Directory Address (911 Address or PO Box only No City Listed) No (You may be contacted by our contracted directory publisher for additional information). If yes, list heading you prefer (ie., Hardware, Plumbers, Grocers): AUTHORIZATION TO ENTER PREMISES I/We do hereby authorize and request that Central Texas Telephone Cooperative, Inc. allow its employees to enter any residence or other building that I/We own for the purpose of installing, repairing or servicing telecommunications equipment when I am not physically present at such residence or other building. This authorization shall remain effective until it is revoked by a written revocation signed by me and filed with the home office of Central Texas Telephone Cooperative, Inc. in Goldthwaite, Texas. EXECUTED THIS DAY OF, 20 Signature Spouse Signature (if applicable) SAFETY PRECAUTIONS Do you have animals on your property? Are the animals aggressive? Are they restrained? LOCATION OF PROPERTY FOR TELEPHONE SERVICE IF CONSTRUCTION IS REQUIRED TO PROVIDE SERVICE TO YOUR LOCATION, AN EASEMENT WILL BE REQUIRED Telephone number where you may be reached concerning installation 911 Address (required) Inside city limits? If yes, what city? County Location School District Location If yes, please list the previous occupants name and telephone number Is the building wired for a telephone? Yes Description of Property and House Neighbors or Road on the: North East West South If you are not the landowner, please give the landowner s name and phone #, if known. PLEASE HELP US FIND YOUR HOUSE. Using the back of the application or a separate sheet, draw a map of the location where you want service. Indicate highways, county road numbers, and any significant landmarks that may assist us in locating the property.

4 APPLICATION FOR MEMBERSHIP AND TELEPHONE SERVICE, PAGE 3 One of the following membership options MUST be selected: MEMBERSHIP OPTIONS AND AGREEMENT Office Use Only: Member # Telephone # 1. I have not had phone service with CTTC previously. I wish to procure telephone service from the Cooperative and thereby establish membership with the Cooperative. Please check one: (Individual or Business) Please note, in order for a husband and wife to hold a joint membership, both parties must sign this application. When both sign, the term member shall be deemed to include a husband and wife holding a joint membership and any provisions relating to the rights and liabilities of membership shall apply equally with respect to the holders of the joint membership. The vote of either separately or both jointly shall constitute one vote as a member of the Cooperative. 2. I have previously had membership with CTTC as a single individual or business operating under my social security number. My marital status or business form has not changed and I thereby wish to re-establish service under the member number previously assigned to my account. 3. I currently have service with the Cooperative. My marital status has changed and I thereby wish to apply for a new single membership with the Cooperative. I understand that all capital credit allocations under the previous joint membership will remain in the joint names only and cannot be transferred to a single membership unless addressed in a divorce decree and provided to the Cooperative. 4. I currently have service with the Cooperative. My marital status has changed and I thereby wish to apply for a new joint membership with the Cooperative. I understand that all capital credit allocations under my previous single membership will remain in my name only. Upon my death, these allocations cannot be transferred to my spouse. I understand in applying for joint membership that, in order for a husband and wife to hold a joint membership, both parties must sign this application. When both sign, the term member shall be deemed to include a husband and wife holding a joint membership and any provisions relating to the rights and liabilities of membership shall apply equally with respect to the holders of the joint membership. The vote of either separately or both jointly shall constitute one vote as a member of the Cooperative. 5. I currently have service with the Cooperative. My marital status has changed and I thereby wish to convert my single membership to a joint membership as provided in the Cooperative s By-Laws Article 1 Section 4(a) which states that A membership may be converted to a joint membership upon the request of the holder thereof and the agreement by such holder and his or her spouse to comply with the articles of incorporation, By-Laws, and any rules and regulations adopted by the Board. I understand that the membership certificate shall be reissued by the Co-op in such a manner as shall indicate the changed membership status and that all capital credit allocations under my single membership will be transferred from my single membership to my joint membership from the date of original application continuing until disconnection of telephone service. Upon death of either spouse who is a party to the joint membership, such membership shall be held solely by the survivor. 6. I currently have service with the Cooperative and hold a joint membership with my deceased spouse. I wish to convert the joint membership to a single membership in accordance with Article 1, Section 4(b) of the Cooperative s By-Laws which state Upon the death of either spouse who is a party to the joint membership, such membership shall be held solely by the survivor. The outstanding membership certificate shall be surrendered, and shall be reissued in such manner as shall indicate the changed membership status, provided, however, that the estate of the deceased shall not be released from any debts due the Co-Op. 7. I currently receive service with the Cooperative through the single membership of my deceased spouse. I understand that all capital credit allocations under the single membership of my deceased spouse shall remain in that name only and cannot be transferred to me. However, I wish to continue receiving telephone service from the Cooperative and thereby request to establish a single membership with the Cooperative. In doing so, I understand that I may still have the directory listing in the name of my deceased spouse or other listing that I may choose. The undersigned (hereinafter called the Applicant ) hereby applies for membership in and agrees to take telephone service from a corporation organized under the laws of the State of Texas under the name of Central Texas Telephone Cooperative, Inc. (hereinafter called Cooperative ), for the purpose of furnishing telephone service, upon the following terms: 1. The Applicant will pay upon signing this application, an estimated installation fee as set forth in the General Exchange Tariff of the Cooperative. An additional deposit may also be required to establish credit. 2. The Applicant will, when telephone service becomes available, take from the Cooperative, telephone service to be used on the premises described herein and will pay monthly at rates to be determined from time to time in accordance with the procedure specified in the By-Laws of the Cooperative. It is expressly understood that all amounts paid by the Applicant in excess of the operating costs of the Cooperative are furnished by the Applicant as capital and the Applicant shall be credited with the capital so furnished as provided by the By-Laws. 3. By signing this application, providing the Applicant is the owner, the Applicant does grant to the Cooperative a right-of-way easement of not less than twenty (20) feet wide to construct, operate and maintain a telephone line or system on the land described, to cut and trim trees and shrubbery that may interfere with or threaten to endanger the operation and maintenance of said line or system and in or upon all streets, roads or highways abutting said land. 4. The Applicant will comply with and will be bound by the provisions of the Charter and By-Laws of the Cooperative and such rules and regulations as may from time to time be adopted by the Cooperative. 5. The Applicant, by becoming a member, assumes NO personal liability or responsibility for any debts or liabilities of the Cooperative, and it is expressly understood that his private property is EXEMPT from execution for any such debts or liabilities. 6. Applicant agrees that venue will be fixed in state district court in Mills County, Texas for the resolution of any and all types of claims or conflicts between Applicant/Member and the Cooperative. 7. All payments are due and payable at the Cooperative s place of business or as stated on your telephone bill. 8. The Cooperative may, at any time, and at its sole discretion, revoke the privilege of extending credit to the Applicant for future services. 9. The Cooperative, or its designee, is expressly authorized to investigate any references, and other information furnished by the undersigned Applicant, or by any other person or entity pertaining to the undersigned Applicant s creditworthiness. 10. This application authorizes the Cooperative or its designee to verify Applicant s creditworthiness by obtaining a credit report, or by directly contacting banks, lending institutions, and suppliers in connection with this application or later in connection with an update, and specifically agrees to a continuing verification as to any trade, credit or bank reference by the Cooperative from year-to-year until said account is paid in full, or this authorization is revoked in writing. 11. If any clause or provision of this Application is found to be invalid or is incapable of being enforced by any rule of law or public policy, all other clauses and provisions shall, nevertheless, remain in full force and effect. ***IF CONSTRUCTION IS REQUIRED TO PROVIDE SERVICE TO YOUR LOCATION, AN EASEMENT WILL BE REQUIRED*** Applicant Signature (Individual or Business) Printed Name (and title, if business) Date Spouse Signature (required for joint membership) Printed Name Date

5 Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No X Form W-9 (Rev )

6 CUSTOMER PROPRIETARY NETWORK INFORMATION (CPNI) Important Customer Notice Federal law and regulations require Central Texas Telephone Cooperative (CTTC) to protect the privacy of your call detail information on file with CTTC. This information includes specific telephone call data, such as the number called, time, location, or call duration. The rules prohibit CTTC from releasing any call detail information during customer-initiated telephone contact without first verifying that the identity of the caller matches the customer name on the account. The FCC has expressed concern that individuals pretending to be customers are attempting to obtain call detail information from telecommunications companies by calling to discuss billing questions. Consequently, the rules require CTTC to verify that a customer calling is really actually the customer. Accordingly, CTTC will share call detail information only with you, our customer, under two circumstances: a) you may come into our office to ask questions and present a valid photo ID matching the name on the account; or, b) you can call us with your billing questions and tell us the call detail information on your bill that you are questioning, such as telephone number called and time of call. If you decide to call us with a billing question but do not have a copy of your bill, the FCC s rules provide three alternatives: (1) You can ask us to call you back to discuss your billing questions. However, we can only call the telephone number that is listed on your account; (2) You can request that a copy of your bill be sent to you at the billing address listed in our account records. When you receive it, you can call us and provide the call detail information when you ask your question; or, (3) You can provide us with a pre-established password, and then we can discuss your billing questions. If you wish to establish a password for your account to facilitate the discussion of your billing questions over the phone, please contact a CTTC Customer Service Rep at (325) or (800) In addition, if you wish to add an individual as an authorized user of your account, and enabling that individual to obtain call detail information on your behalf, please contact us. If you wish to rely on someone else to discuss account changes, payments, or any call detail information, you must add that person s name to your account. Any contact(s) that you authorize will not be responsible for payment of this account.

7 IMPORTANT CUSTOMER NOTICE REGARDING CUSTOMER PROPRIETARY NETWORK INFORMATION Federal law protects your privacy rights as a customer of Central Texas Telephone Cooperative (CTTC). These rights are in addition to the existing safeguards that CTTC already has in place to ensure your privacy rights. The Federal Communications Commission (FCC) requires CTTC to notify you as a subscriber of your right to restrict the use of, disclosure of, and access to your Customer Proprietary Network Information (CPNI). You have the right, and CTTC has a duty, under Federal law, to protect the confidentiality of your CPNI. CPNI: CPNI is information you might consider private and therefore wish for CTTC to protect it from use for marketing purposes. CPNI is information CTTC possesses solely due to the customer-carrier relationship that is necessary for the company to serve your telecommunications needs. CPNI is defined by the FCC as information that relates to the quantity, technical configuration, type, destination and amount of use of a telecommunications service subscribed to by any customer of a telecommunications carrier and that is made available to the carrier by the customer solely by virtue of the carrier-customer relationship; and information contained in the bills pertaining to telephone exchange or toll service received by a customer of a carrier. CPNI does not include information that is in the public domain or available from other, non-company sources. For example, census data, subscriber list information and published directory information is public data. PERMITTED USE OF CPNI BY COMPANY WITHOUT YOUR PERMISSION: CPNI can be used by the CTTC for certain purposes without your permission. CTTC may use CPNI to offer you new or enhanced services that are related to the category of services to which you currently subscribe. CTTC may also use CPNI to respond to your inquiry regarding services you currently use or related services CTTC offers. In addition, CTTC may use CPNI in connection with repair and maintenance services, billing and collection, to protect CTTC property and to prevent fraud. PROHIBITED USE OF CPNI UNLESS AUTHORIZED BY YOU: Without your authorization, CTTC may not use your CPNI to market other communications services that it provides that are unrelated to the services you already purchased. For example, CTTC may not use CPNI to offer you any type of long distance or wireless service unless you currently subscribe to such long distance or wireless services. In addition, CTTC may not share CPNI with any other company, including our affiliate that offers communications related services, unless you are also a customer of our affiliate. MAY WE USE YOUR CPNI TO BETTER INFORM YOU OF OTHER SERVICE OFFERINGS? CTTC and its affiliate company provide a vast array of telecommunication services including local, long distance, wireless TV and Internet access. We want to assure you that we always take great care in the way that we handle sensitive information that pertains to your account, known as CPNI. CTTC requests permission to use your CPNI to more effectively meet your telecommunications needs. CTTC might want to contact you to advise you of new services, pricing alternatives or special offers that CTTC believes may interest you based on the telecommunications services you currently purchased.

8 IMPORTANT CUSTOMER NOTICE REGARDING CUSTOMER PROPRIETARY NETWORK INFORMATION Page 2 With your permission, only CTTC and its affiliate, will use your CPNI. CPNI data will not be shared with any other company or entity without your approval, except to provide the service or services to which you are already subscribed, or where we are required or authorized by law, regulation or other controlling authority to share the information with an outside party. With this in mind, we would like you to know that FCC regulations give you a choice a choice about how CTTC can use your CPNI to let you know about the availability of innovative services offerings that you may have not anticipated or even knew that we were able to provide. You will also be able to enjoy savings and may even be able to combine all these services on one monthly bill. If you agree to give CTTC permission to use your CPNI, you do not need to take any further action. If you do not agree to give CTTC permission to use your CPNI as described, you may opt-out by notifying us within the next 30 days in the following manner: (1) Call the CTTC office at (325) or (800) within 30 days to register your request. You may call anytime, twenty-four hours a day, seven days a week; or (2) Complete the information below and return it to CTTC, PO Box 627, Goldthwaite TX 76844; or, (3) CTTC at Be sure to include in your the name that appears on your account with CTTC, the telephone number associated with your account and a statement that you wish CTTC to restrict use of my CPNI. OPTING OUT DOES NOT AFFECT YOUR CURRENT SERVICE: The restriction will remain in effect until you notify us otherwise. Restricting use of your CPNI will not affect the services that you currently have with CTTC and its affiliate. Please note that restricting your CPNI will not eliminate all of our marketing contacts with you. You could still receive marketing contacts from us that are not based on your CPNI. Also, CTTC and its affiliate may use your CPNI to contact you about service offerings related to the services to which you already subscribe or to market other service offerings with your permission in the context of a customer service call. YOU CAN ALWAYS CHANGE YOUR MIND: You can always change your mind about CTTC S use of CPNI simply by telling us. Your instructions will remain in effect until you revoke or limit that approval or denial. (Please be aware that every two years, you will receive a notice similar to this one to remind customers of their options). Regardless of whether you decide to opt out or not, CTTC is committed to continuing to provide you with the same high quality services that you have come to expect from us. If you have any questions, or would like additional information regarding our use of CPNI, please contact customer service at (325) or (800)

9 IMPORTANT CUSTOMER NOTICE REGARDING CUSTOMER PROPRIETARY NETWORK INFORMATION Page 3 CPNI OPT-OUT SIGNATURE FORM By signing this Opt-Out Form, I am informing Central Texas Telephone Cooperative, Inc., its affiliate and authorized agents, not to sell, trade, or share my CPNI data with any other company or entity outside of CTTC, or others authorized to represent them, to offer products and services, except as authorized by law. Date: Customer Signature: Customer: (please print) Address: Telephone Number: ================================================================ System Input Complete Customer Service Rep: Date:

10 CENTRAL TEXAS TELEHONE COOPERATIVE, INC. ** Customers need to call the carrier of your choice to set up an account. The carrier should give you a CIC (carrier identification code) that you need to give to CTTC so we can set up the carrier in our switch. ** INTERLATA LONG DISTANCE CARRIERS INTRALATA LONG DISTANCE CARRIERS QWEST QWEST Business Business Residential Residential NTS NTS Business Business Residential Residential FRONTIER FRONTIER Business Business Residential Residential MCI MCI Business Business Residential Residential EXCEL EXCEL Business Business Residential Residential COAST INTERNATIONAL CENTRAL TEXAS TELEPHONE COOP Business Business Residential Residential CENTRAL TEXAS COMMUNICATIONS CENTRAL TEXAS COMMUNICATIONS Business Business Residential Residential CABLE & WIRELESS CABLE & WIRELESS Business Business AT&T AT&T Business Business Residential Residential Revised 1/6/15

11 PIC FREEZE AUTHORIZATION FORM (It is Strongly Recommended but not required that you authorize a PIC FREEZE) The purpose of a freeze is to prevent a change in your telephone company without your consent. A freeze is a protection against slamming (switching your telephone company without your permission). You can impose a freeze on either your local toll or long distance service provider, or both. If you authorize a freeze, you must contact CENTRAL TEXAS TELEPHONE COOP., INC. at or (800) to lift the freeze before you can change your service provider. You may add or lift a freeze at any time at no charge. Customer billing name: Customer service address: City, State, Zip code: Customer mailing address: City, State, Zip Code: Telephone number (1) Telephone number (2) Telephone number (3) Customer s month and year of birth, mother s maiden name, or last four digits of The customer s social security number: I authorize a freeze for the telephone number(s) listed above for local toll service. Current preferred local toll company: Customer s signature: Customer s printed name: Date: I authorize a freeze for the telephone number(s) listed above for long distance service. Current preferred long distance company: Customer s signature: Customer s printed name: Date: Mail or fax this form to: Central Texas Telephone Cooperative, Inc. P O Box 627 Goldthwaite Texas Fax Number:

12 CERTIFICATION FOR PER-LINE BLOCKING I am a customer of Central Texas Telephone Cooperative. I understand that I already have per-call blocking. However, I certify that I have a compelling need for per-line blocking. I understand I can remove per-line blocking and go back to per-call blocking at no charge by calling Central Texas Telephone Cooperative business Office. I understand that my calls to those who have activated Anonymous Call Rejection will not be completed as dialed unless I call from a different number, payphone or cellular phone, or make a credit card or operator-assisted call, or dial *82 or 1182 on my phone before dialing the telephone number. I request that per-line blocking be installed on my line at no charge. I do not want per-line blocking on my line even though my number is unlisted. By choosing this, my phone number will show up on Caller ID. I acknowledge that I have read and understand the information about Caller ID. I represent that I am authorized to request establishment of per-line blocking on the line number identified below. Area Code/Phone Number (s) Residence Number Business Number Printed Name as it appears on Customer Bill Address City, State, Zip Code Signature Date

13 CENTRAL TEXAS COMMUNICATIONS, INC. PO Box 627 Goldthwaite, TX or Automatic Payment Authorization Form - OPTIONAL Customer Name Type of Service: Telephone Account # Internet Account # Contact # Customers may pay their account each month by Credit Card or ACH Bank Deduct. If you choose one of these options, your bill will be mailed to you on the first of each month and will be noted Credit Card Do Not Pay or Bank Deduct Do Not Pay. Automatic monthly payments are processed between the 5 th and 7 th day of each month. There is NO CHARGE for these services. To authorize an automatic payment option, complete one of the options below and return to our office. By signing below, I am giving CTTC/CTC authorization to debit my Credit Card or Bank Deduct my account each month for payment of the net amount on my bill(s). I understand CTTC/CTC will continue to debit my Credit Card or Bank Deduct my account each month for the service(s) checked above until I provide notice to CTTC/CTC to discontinue this authorization. CREDIT CARD AUTHORIZATION FORM Type of Credit Card: Visa Credit Card # Exp Date MasterCard Credit Card # Exp Date Discover Credit Card # Exp Date Name on Card Mailing Address (Address where you receive your credit card statement) Signature Authorization Code (3-digit code on back of card) Zip Code Date ACH BANK DEDUCT AUTHORIZATION FORM (Please Include a voided check) of Name of Bank City and State Bank ID Number Signature Personal Account Number Date

14 NON-RESIDENTIAL CUSTOMERS PLEASE NOTE Texas Prompt Payment Act Notice If your organization is a state agency or political subdivision, your organization may qualify for billing treatment under the Texas Prompt Payment Act. Central Texas Telephone Cooperative, Inc. requests that you identify yourself as eligible for Texas Prompt Payment Act billing treatment. You may call our business office at or write to us at PO Box 627, Goldthwaite, TX If you identify your organization as eligible for Prompt Payment Act billing treatment, we will request that you provide a tax exempt certificate or affidavit to document your eligible status. If you have questions about whether your organization qualifies for billing treatment under the Texas Prompt Payment Act, please review Texas Government Code Chapter Alternatively, you can contact the State Comptroller s office at or them at WebFileHelp@cpa.state.tx.us. If you have any questions, please feel free to contact us by one of the above ways. Central Texas Telephone Cooperative, Inc. PO Box 627 Goldthwaite, TX

15 Privacy Policy Regarding the Collection and Use of a Customer s Social Security Number 1. How your social security number is collected. We obtain your social security number when you apply for service. 2. How your social security number is used. Your social security number is obtained because we will be extending credit to you by billing you after the services have been provided to you. We also use your social security number as an additional means to verify your identity and distinguish you from other customers with the same or similar name and to administer the LITE-UP Texas Program. 3. How do we protect your social security number? We are sensitive to your concerns that your social security number might fall into the wrong hands, which could result in identity theft or general access to your personal information by unauthorized persons. Your Application for service, and any other documents containing your social security number, is filed in a secure location to which only a limited group of authorized personnel have access. Personnel who receive your Application have strict instructions to immediately transport such documents to the secure area and to not permit such documents to remain on desks, in baskets or elsewhere in general work areas where they could be seen by unauthorized personnel. Personnel are prohibited from copying or in any way duplicating documents containing your social security number except duplication by instruction of authorized personnel for an authorized purpose. Your social security number does not appear in electronic form accessible on our network by any employees not authorized to have access to your social security numbers. Firewalls, passwords and other safeguards have been installed in our network to restrict access to your social security number to those employees so authorized. Employees authorized to have access to your social security numbers are prohibited from saving your social security number, in any fashion, on a the hard drive of any laptop or other stand alone computer not saving data on our network. We will not include your social security number on any documents, such as monthly statements, for which it serves no purpose. We need your social security number on file for the purposes stated but will not use it unnecessarily so as to limit the opportunity for it to be inadvertently disseminated.

16 Privacy Policy Regarding the Collection and Use of a Customer s Social Security Number Page 2 All employees who will come in contact with your social security number are provided initial training before they are permitted to handle any document containing social security numbers and will be reminded, through periodical updated training, of the importance of protecting the privacy of social security numbers and our policies which have been designed to insure such protection, asserting the need to safeguard customers social security numbers. Before discarding any customer records, employees are to shred any portion of the records that contain a customer's social security number. 4. Who can access your social security number? Personnel, or clerical staff who open mail, will have access to documents containing your social security number. If your account is turned over for collection purposes and the attorney/collection agency requests your social security number to assist in collection proceedings, we will provide your number to them as our agent. If we receive a subpoena or Court order compelling us to turn your records over to a law enforcement agency or investigator or to a party in connection with a legal proceeding, then we will release them, including your social security number, as required by law. If the subpoena is issued in a civil matter, you should have the opportunity to seek a protective order or to quash the subpoena to protect the confidentiality of your information. 5. How will we eventually dispose of your social security number? Once you terminate service and pay all amounts owed to us on your account, you may request that we destroy any records containing your social security number. Upon such request, such documents will be shredded and any electronic records will be permanently deleted. If no request is received from you after service is terminated and fully paid for, we will retain your records in accordance with our record retention policy and this privacy policy. If we elect to destroy your records in accordance with our policy, the records containing your social security number will be shredded and any electronic records containing your social security number will be permanently deleted.

17 Texas Low-Income Telephone Program Central Texas Telephone Cooperative wants you to know about discounted rates offered in our area through the Texas Low-Income Telephone Program. Every Person in America should have access to affordable telecommunications service. You may qualify for reduced rates for these services. HOW DO I QUALIFY? If you or someone residing in your household participates in any one of these programs.... Food Stamps (Supplemental Nutrition Assistance Program) Medicaid Children s Health Insurance Program (CHIP) Low-Income Energy Assistance Lifeline Supplemental Security Income, or Federal Public Housing Assistance.... You can receive reduced rates. In addition, you may also qualify if your household annual income is at or below 150% of the federal poverty guidelines. HOW DO I APPLY? Contact Lifeline toll-free at (866) , or write them at 1779 Wells Branch Parkway, Suite 110B #357, Austin TX , or call Central Texas Telephone Cooperative at (325) or toll free at (800) Para preguntas relacionadas a LIFELINE Texas llame gratis a: C e n t r a l Te x a s Te l e p h o n e C o o p e r a t i v e, I n c Reilly Goldthwaite TX * * * * 208 E. Brown San Saba TX Phone: (325) (800) Fax: (325) cttc@centex.net THE HOMETOWN ADVANTAGE