Acct/Capital Credit No. Assigned Phone Number. Contact made by Date of Installation. Membership $ Installation $ Deposit $ Other $ TOTAL PAID $

Transcription

1 PINELAND TELEPHONE COOPERATIVE, INC. 30 S Rountree Street Post Office Box 678 Metter, Georgia FAX: OFFICE USE ONLY NO PERSONAL CHECKS ACCEPTED CURRENT PHOTO ID REQUIRED LIFELINE & LINK UP: $54.00 if qualified residential RESIDENTIAL: $35.00 if phones are in place $ to install 1 (one) residential phone BUSINESS: $47.00 if business phones are in place $ to install 1 (one) business phone Acct/Capital Credit No. Assigned Phone Number Contact made by Date of Installation Membership $ Installation $ Deposit $ Other $ TOTAL PAID $ COMPLETE AND RETURN WITH FEE: Name: Nationality: White Black Hispanic Other County: E-911 Address: (required) Inside City Limits Outside City Limits Billing Address: Directions to residence of installation: Contact Number: Neighbor with phone service: Place of employment: (source of income) Type of job: (position) How long employed? Married: Name of spouse or other adult living there: Previous Address: Previous Telephone Service: SOCIAL SECURITY NUMBER Previous Telephone Number: Date Disconnected: INSIDE WIRE MAINTENANCE $ 3 per month (per account) YES NO I WANT Pineland Telephone Cooperative, Inc. to do the INSIDE WIRE MAINTENANCE for my telephone service through the monthly Inside Wire Plan. I understand for Pineland to maintain my inside wiring, it must be wired to conform to the rigid standards set forth by Pineland Telephone Cooperative. A qualified technician may come on site to inspect the wiring. I understand that if I do not want to participate in the Inside Wire Plan, I assume responsibility for that maintenance myself and if repairs are needed and Pineland agrees to do the work, there will be a charge based on the time and material required to do the job. DIRECTORY INFORMATION: I understand that as per the Georgia Public Service Commission: AN UNLISTED TELEPHONE NUMBER does not mean that my telephone number will not be Is name to be listed in directory? YES NO displayed on a called party s Caller ID box. I also understand that in order to prevent my telephone number from being delivered to the called party that I MUST DIAL *67 BEFORE EACH CALL. List in directory as: Name: Address: Type of Business (For Yellow Page Heading): Signature Date Revised: 7/

2 TELEPHONE SERVICE TELEPHONE INSTALLATION TYPE OF TELEPHONE(S) Residence: Pineland Telephone(s): Business: Jack(s) in place: Yes No CLASS/CUSTOM CALLING FEATURES and BUNDLED SERVICES CALLING FEATURES DISCOUNT WHEN ORDERING ADVANCE CALLING FEATURES Customer Telephone(s): BUNDLED SERVICES Residential Customers Only Anonymous Call Rejection Auto Call Back *66 Auto Recall *69 Call Forwarding: Call Waiting: Caller ID (number): Caller ID (name/number): Caller ID/Call Waiting: Distinctive Ringing: Select Call Acceptance *64: Select Call Forwarding *63: Select Call Rejection *60: Speed Calling 8: Speed Calling 30: Teen Service: Telemarketer Call Screening: Three-way Calling: VOICE MAIL: Call Answering: 10 msgs Voice Messaging: 20 msgs Voice Messaging Prem: 30 msgs LONG DISTANCE: $0.50 Discount for any 2 Choices $1.50 Discount for any 3 Choices $2.00 Discount for any 4 Choices $3.00 per month... ACR $3.00 per month... ACB $3.00 per month... AR $2.00 per month... RCLF $3.00 per month... RCLW $3.00 per month... CID $4.75 per month... CNM $9.25 per month... CWID $3.00 per month... SDF $3.00 per month... SCA $2.00 per month... SCF $3.00 per month... SCR $2.00 per month... RP8 $3.00 per month... RP30 $3.00 per month... TEEN $3.00 per month... TSCR $3.00 per month... R3WY $3.00 per month... VM2 $5.00 per month... VM3 $7.00 per month... VM4 800 Access Only $4.00 per month Third Number Restriction: Collect Restriction: NO CHARGE NO CHARGE 900 Restriction: NO CHARGE International Call Block NO CHARGE C ustomer onnections TELEPHONE Telephone Service Wire Maintenance Caller ID/Call Waiting Voice Mail 3-Way Calling That save you a Bundle! Basic Connection...PNBNDESCN LONG DISTANCE 100 minutes of Pineland Long Distance (No Carry Over) Ultimate Connection TELEPHONE Telephone Service Wire Maintenance Caller ID/Call Waiting Voice Mail 3-Way Calling LONG DISTANCE 200 minutes of Pineland Long Distance (No Carry Over) INTERNET Unlimited 256 DSL Internet Bundle $37.65 a month Does Not Include Taxes You save $7.47 per month $89.64 per year Bundle...PNBNDULCN $71.65 a month Does Not Include Taxes You save $8.42 per month $ per year All services not available in all areas. Pineland Telephone residential connection bundles apply to residential service only. Charges do not include FCC charges or federal, state and local taxes. Long Distance applies to calls made within the continental United States. Monthly long distance minutes apply only to calls made from the telephone number you select for your bundle and cannot be combined with any other telephone numbers or additional telephone lines, whether in the home or elsewhere. Long distance minutes exceeding the monthly bundle allotment will be billed at 10 cents per minute. 2.

3 BUSINESS SIGNATURE REQUIRED: DO-NOT-CALL SOLICITOR NOTIFICATION TYPE OF BUSINESS: Federal Tax ID Number: Proprietorship Corporation Partnership Other Name of Proprietor: Name of Corporation: Names of Partners: Legal Entity Name: The State of Georgia, the Federal Communications Commission (FCC) and the Federal Trade Commission (FTC) have established a state and national Do Not Call Registry. The FCC requires us to notify businesses that use our service to make telephone solicitations (telemarketing calls) about the Do Not Call Registry rules and regulations. We are providing this notification to all new and existing business customers because we have no way of determining which ones may use our service to make telephone solicitations. If you are a business, individual or other entity that makes telephone solicitations, it is very important that you familiarize yourself with the rules and regulations for compliance with the Do Not Call Registry. Unless you are covered by one of the exemptions established in the FCC/FTC rules, you may not make calls to numbers included in the Do Not Call Registry. Before you rely on one of the exceptions, you should consult the rules. For information concerning the rules and regulations, you may visit the Do Not Call Registry at You can find the FCC and FTC rules governing telemarketing and telephone solicitation at 47 C.F.R Section and 16 C.F.R. Part 310, respectively. Date: BUSINESS/RESIDENTIAL SIGNATURES CREDIT HISTORY INQUIRY By signature, I acknowledge that in processing my application for service with Pineland Telephone Cooperative, Inc., a complete credit history inquiry will be obtained. (Credit Report) _ Date: BILLING NAME AND ADDRESS (BNA) NON-DISCLOSURE STATEMENT I,, request that my billing name and address not be disclosed by Pineland Telephone Cooperative, Inc. to interchange carriers. GUARANTEE OF ACCOUNT: For and in consideration of the goods and services rendered and to be rendered by Pineland Telephone Cooperative, Inc., the undersigned guarantor hereby guarantees both individually and on behalf of payment of all fees and charges. Should the account become delinquent and be referred for collection to an attorney, the undersigned agrees to pay reasonable attorney fees, all costs of collection and interest at 1½ % per month on the unpaid balance. All charges are due 30 days after bill date. 3.

4 LONG DISTANCE (Intralata) Pineland Telephone Cooperative, Inc. Equal Access Intralata Carriers 30 S. Rountree Street * P.O. Box 678 * Metter, Georgia * or Select one of the companies listed to be your Intralata Dial 1 Plus Long Distance Company by placing a check next to the name of the company of your choice. This is a rotating alphabetical list of carriers available to you. The order in which the companies are listed does not indicate a preference or a recommendation. Please record your choice for your records. I understand that: It is my responsibility to call the long distance carrier at the number listed and set up my account. (Pineland will set up Pineland Long Distance customers.) For my protection, a PIC FREEZE will be placed on my line so that no changes can be made to my long distance without my verbal or written consent. ATC LONG DISTANCE RESIDENCE: BUSINESS: ACCESS CODE: AT&T THE RIGHT CHOICE BUSINESS: RESIDENCE: ACCESS CODE: BELL SOUTH BUSINESS: RESIDENCE: BTI BUSINESS: ACCESS CODE: CORP TELEMANAGEMENT GROUP BUSINESS ONLY: ACCESS CODE: GTE LONG DISTANCE BUSINESS: RESIDENCE: ICI COMMUNICATIONS BUSINESS: ACCESS CODE: INTERLINK TELECOM INC. P.O. BOX 1447 COVINGTON, GA BUSINESS: ACCESS CODE: IXC CODE 457 DIAL 8 SAVE BUSINESS: ACCESS CODE: IXC LONG DISTANCE, INC. BUSINESS: RESIDENCE: ACCESS CODE: MCI TELECOMMUNICATIONS CORP. BUSINESS: RESIDENCE: ACCESS CODE: OPTICOM INC. ACCESS CODE: PINELAND LONG DISTANCE BUSINESS: RESIDENCE: ACCESS CODE: QUEST/LCI, INTERNATIONAL BUSINESS/RES.: ACCESS CODE: 0432 RCI LONG DISTANCE BUSINESS/COIN: RESIDENCE: TTY HEAR IMPAIR: ACCESS CODE: SPRINT DIAL 1 SERVICE BUSINESS: RESIDENCE: ACCESS CODE: TELEDIAL AMERICA BUSINESS: RESIDENCE: ACCESS CODE: VARTEC TELECOM INC BUSINESS: ACCESS CODE: VERIZON LONG DISTANCE BUSINESS: RESIDENTIAL: ACCESS CODE: WILTEL, INC. BUSINESS: RESIDENCE: ACCESS CODE:

5 LONG DISTANCE (Interlata) Pineland Telephone Cooperative, Inc. Equal Access Interlata Carriers 30 S. Rountree Street * P.O. Box 678 * Metter, Georgia * or This is a rotating alphabetical list of carriers available to you. The order in which the companies are listed does not indicate a preference or a recommendation. Please record your choice for your records. Select one of the companies below to be your Interlata Dial 1 Plus Long Distance Company by placing a check next to the name of the company of your choice. I understand that: When choosing a carrier, it is my responsibility to call the carrier at the number listed and set up my account. (Pineland will set up Pineland Long Distance customers.) For my protection, a PIC FREEZE will be placed on my line so that no changes can be made to my long distance without my verbal or written consent. ATC LONG DISTANCE RESIDENCE: BUSINESS: ACCESS CODE: AT&T THE RIGHT CHOICE BUSINESS: RESIDENCE: ACCESS CODE: BTI BUSINESS: ACCESS CODE: CABLE & WIRELESS BUSINESS ONLY: ACCESS CODE: CORP TELEMANAGEMENT GROUP BUSINESS ONLY: ACCESS CODE: ETI BUSINESS: ACCESS CODE: GTE LONG DISTANCE BUSINESS: RESIDENCE: I-LINK/FTI COMMUNICATIONS MAKING COMMUNICATIONS SMARTER BUSINESS: RESIDENCE: ACCESS CODE: ICI COMMUNICATIONS BUSINESS: ACCESS CODE: INTERLINK TELECOM INC. P.O. BOX 1447 COVINGTON, GA BUSINESS: ACCESS CODE: IXC CODE 457 DIAL 8 SAVE BUSINESS: ACCESS CODE: IXC LONG DISTANCE, INC. BUSINESS: RESIDENCE: ACCESS CODE: MCI TELECOMMUNICATIONS CORP. BUSINESS: RESIDENCE: ACCESS CODE: NYNEX LONG DISTANCE BUSINESS: RESIDENCE: ACCESS CODE: OPTICOM INC. ACCESS CODE: PINELAND LONG DISTANCE BUSINESS: RESIDENCE: ACCESS CODE: QUEST/LCI, INTERNATIONAL BUSINESS/RES.: ACCESS CODE: 0432 RCI LONG DISTANCE BUSINESS/COIN: RESIDENCE: TTY HEAR IMPAIR: ACCESS CODE: SPRINT DIAL 1 SERVICE BUSINESS: RESIDENCE: ACCESS CODE: TELEDIAL AMERICA BUSINESS: RESIDENCE: ACCESS CODE: THE PHONE COMPANY BUSINESS: RESIDENCE: ACCESS CODE: VARTEC TELECOM INC BUSINESS: ACCESS CODE: VERIZON LONG DISTANCE BUSINESS: RESIDENTIAL: ACCESS CODE: Signature: 5.

6 EASEMENT GRANTED TO PINELAND TELEPHONE COOPERATIVE, INC. In consideration of the benefits to be received and of other good and valuable consideration received from Pineland Telephone Cooperative, Inc., I (We) hereby grant said Cooperative, their respective licensees, successors and assigns, the right to construct, operate and maintain, add or remove lines or systems of communication consisting of such buried cables and wires, terminals, markers, poles, guys, anchors, as the Cooperative may require upon, across, over and under that certain tract of land located in County, State of Georgia. Said right includes the privilege to cut and trim said right of way of shrubbery and trees prior to construction and to keep said right of way cleared of such growth that may interfere with the safe operation and maintenance of the lines or system. Pineland Telephone Cooperative, Inc. hereby is granted the right to ingress and egress to said premises at all times for the purpose of inspecting, maintaining and clearing of said easement. The undersigned agree that all cables and other facilities shall remain the property of the Cooperative, removable or abandoned at the option of the Cooperative, upon termination of service requiring the easement. In witness whereof, the undersigned have set their hand and seal this day of in the year. Sign Print Date Signed in the presence of: Witness: 6.

7 Telephone Acct. No.: I,, authorize Pineland Telephone Coop, Inc. to add the name of, Driver s License # or last 6 digits of Social Security Number, to my account for purposes of making changes or accessing information. I understand that it is my responsibility to advise Pineland Telephone if the name of this added individual should change. Signature PLEASE ATTACH LEGIBLE COPY OF AT LEAST ONE FORM OF PICTURE ID FOR BOTH THE OWNER OF THE ACCOUNT AND THE INDIVIDUAL BEING ADDED. THANK YOU.