APPLICATION FOR COMMUNICATIONS SERVICES

Transcription

1 APPLICATION FOR COMMUNICATIONS SERVICES GENERAL INFORMATION Type of service requested Residential Business Legal Name of Applicant Last First MI Applicant (Customer) name and membership name must be the same. Additional forms requiring a signature must be signed by the applicant. Business applications including any additional forms must be signed by the responsible party. Social Security # or Tax ID # Date of Birth Service Address Billing Address (if different) Contact Telephone # Driver License # (Please provide a copy of your Driver License) SERVICE INFORMATION Has location had previous telephone service? Yes No If yes, telephone # (if known) Name of previous occupant Nearest city or community Directions to location Landmarks or entrance description Are gates locked? Yes No If yes, may we install our lock? Yes No Landowner Name Landowner Contact Number (Landowner must furnish completed, notarized Right-of-Way Easement.) For Business Office Use: Rte Ped Pr Eng New Telephone # Date Order Taken Due Date Staking Appointment CSS Service Location Tax Location School District Census Tract 700 Mhz Unlicensed DSL A/C # S.O. # New Member Packet Bill Explanation W-9 Form ROW Easement 1

2 DIRECTORY INFORMATION Would you like the telephone number published, non-published or unlisted? A non-published telephone number is a telephone number, which at the request of the customer is not listed and is not made available to the general public by the Cooperative. There is a monthly fee of $1.00 for a non-published number. An unlisted telephone number is a telephone number, which at the request of the customer is not listed in the telephone directory but is made available by the Cooperative to the general public upon request. There is no charge for an unlisted number. Caller ID per-call blocking is available, at no charge to any customer who wishes to prevent the delivery of their calling party number to the called party by dialing an access code of *67 immediately prior to placing the call. Caller ID per-line blocking is available, at no charge to any customer who wishes to prevent delivery of their calling party number on all calls. Per-line blocking does not prevent transmission of your telephone number when you call a company using an 8XX or 9XX number, therefore, your number may be available to that company s service representative before your call is answered. Your number can be unblocked on a per call basis by dialing an access code of *82 immediately prior to placing the call. Do you wish to have Caller ID per line blocking? Yes No Caller Name ID (Customer s name that will be delivered to their called party.) Directory Listing Name(s) Directory Listing Address (optional) Community Name (required) (Community name is necessary for directory assistance inquiry. Customers residing in CVTC exchanges may prefer to be associated with the community of La Grange for directory assistance instead of their telephone exchange.) Additional Listings (if desired) (The fee for each additional listing is 50 per month per listing.) Yellow Pages Heading (Business Only) (Heading is necessary if customer wants to have listing in yellow pages as well as for directory assistance inquiry clarification, i.e., Colorado Valley Telephone Cooperative is listed under the Heading of Telephone Companies.) AUTHORIZATION INFORMATION Changes to this account that require a signature (i.e., PIC changes) shall be made by the applicant only. Changes to the account that do not require a signature (i.e., adding or removing calling features) may be made by a person or persons that the applicant has authorized. If you, the applicant, wish to authorize another person or persons to make changes to your account, please designate the person or persons below. (Name) (Relationship) (Name) (Relationship) Your account may be further protected with the assignment of a password. The password is optional. Password Answer one of the three security questions below if assigning a password. 1. What is your mother s middle name? 2. What is your favorite food? What city were you born in? 2

3 MONTHLY PAYMENT METHOD Check/Cash (Bill via U. S. Mail) Credit Card (Credit Card Authorization Form required) Automatic Bank Draft (Authorization form required) Online Bill Pay via cvctx.com All services selected by the customer will be billed on a single bill. If the customer selects the Credit Card or the Automatic Bank Draft method of payment, the total amount due will be charged for all services listed on the single bill. If the customer selects Online Bill Pay, this service will be available after receipt of the first invoice. TELEPHONE SERVICES ACTIVATION CHARGES, MONTHLY CHARGES AND LONG DISTANCE RESTRICTIONS Installation Charges (Please check all that apply) Simple Reconnection (no service trip) $29.10 Name Change (no changes to account) $21.50 New Line (brought to the outside only) $60.90 Name Change (changes to account) $29.10 Name Change (same membership) N/C Install jacks while at premises (check if yes) $24.30 How many jacks are required? Monthly Charges (Please check type of Service) Residential Basic Local Service Business Basic Local Service Lifeline Basic Local Service Residential Local Service $16.80 Business Local Service $26.20 Lifeline Local Service $16.80 Fed. Subscriber Line Chg. $ 6.50 Fed. Subscriber Line Chg. $ 6.50 Fed. Subscriber Line Chg. $ Service Fee $ Service Fee $ 0.50 Fed. Lifeline Support Cr. $ Equalization Fee $ Equalization Fee $ 0.06 State Lifeline Support Cr. $ Access Recovery Charge $ 2.00 Access Recovery Charge $ Service Fee $ Equalization Fee $.06 Additional State Support $ -.66 Total BLS* $25.86 Total BLS* $35.26 Total Lifeline Service* *Total BLS does not include all surcharges and taxes Long Distance Restrictions (Please check all that apply) Residential and Business 900 Block No Charge Collect Block No Charge 3rd Party Block No Charge International Block No Charge Residential Monthly Charges Business Monthly Charges Toll Denial $1.75 Toll Denial $2.25 Toll Denial w/800 Access $1.75 Toll Denial w/800 Access $2.25 Toll Denial w/pin Override $2.00 Toll Denial w/pin Override $2.00 If Toll Denial w/pin Override is selected, PIN # will be (4 digits) Lifeline Toll Denial No Charge (allows only local calls) Toll Denial w/ 800 Access No Charge (allows local and toll free calls) Toll Denial w/pin Override No Charge (PIN # allows a toll call to be made) If Toll Denial w/pin Override is selected, PIN # will be (4 digits) 3

4 MAINTENANCE PROTECTION PLAN Maintenance Protection Plan $4.95 Monthly (Available to Residential Service Customers Only) ACCESSIBILITY QUESTION Please check here if you have a hearing or speech disability or condition and that this disability/limitation prevents or limits your ability to communicate over voice networks. Nature of the disability or medical condition: RESIDENTIAL BUNDLED PACKAGES MONTHLY CHARGES CVC Complete $97.95 Includes Access Line with Touch Tone Dialing, 911 Service Fee, 911 Equalization Fee, Subscriber Line Charge and Access Recovery Charge Basic Voice Mail with Call Forwarding-Busy and Call Forwarding-No Answer Calling Name & Number Delivery with Call Waiting ID Unlimited Long Distance (ULD) EXPRESSNET Premium (up to 5 Mbps) and Wireless Router Service CVC Complete Plus $ Includes Access Line with Touch Tone Dialing, 911 Service Fee, 911 Equalization Fee, Subscriber Line Charge and Access Recovery Charge Basic Voice Mail with Call Forwarding-Busy and Call Forwarding-No Answer Calling Name & Number Delivery with Call Waiting ID Unlimited Long Distance (ULD) EXPRESSNET Full Throttle (up to 8 Mbps) and Wireless Router Service CVC Complete (Lifeline)* $83.95 Includes Access Line with Touch Tone Dialing, 911 Service Fee and 911 Equalization Fee Basic Voice Mail with Call Forwarding-Busy and Call Forwarding-No Answer Calling Name & Number Delivery with Call Waiting ID Unlimited Long Distance (ULD) EXPRESSNET Premium (up to 5 Mbps) and Wireless Router Service CVC Complete Plus (Lifeline)* $ Includes Access Line with Touch Tone Dialing, 911 Service Fee and 911 Equalization Fee Basic Voice Mail with Call Forwarding-Busy and Call Forwarding-No Answer Calling Name & Number Delivery with Call Waiting ID Unlimited Long Distance (ULD) EXPRESSNET Full Throttle (up to 8 Mbps) and Wireless Router Service Bundled packages are available to new and existing Residential customers. Applicable surcharges and taxes are not included in bundle pricing. Bundle savings are in comparison to the full price of the individual services included in the bundles. Additional features and services are available as add-ons at their regular rates. *Lifeline bundles are available to Lifeline customers only. 4

5 CALLING FEATURES & SERVICES Special Calling Features Monthly Charges (Please check all that apply) Residential Business Residential Package Prices Automatic Callback Automatic Redial Call Forwarding Call Forwarding-Busy Call Forwarding-No Answer Call Forwarding-Remote Access Call Waiting Direct Line/Manual Line Distinctive Alert/Call Waiting Do Not Disturb Do Not Disturb-Telemarketing Selective Call Acceptance Selective Call Forwarding Selective Call Rejection Speed Dialing (8) Speed Dialing (30) Three Way Calling $1.75 $2.25 $1.75 $2.25 $2.50 $2.50 $2.00 $2.75 $3.00 $3.75 $1.75 $2.25 Two Features $2.50 Three Features $3.50 Four Features $4.50 Five Features $5.50 Add l. Features-each $1.00 Business Package Prices Two Features $3.25 Three Features $4.55 Four Features $6.00 Five Features $7.00 Six Features $8.25 Seven Features $9.75 Eight Features $11.00 Nine Features $12.25 Ten Features $13.25 Anonymous Call Rejection With Calling Name and/or Number Feature Without Calling Name and/or Number Feature Calling Name Delivery Calling Number Delivery Calling Name & Number Delivery Additional Features & Services Monthly Charges (Please check all that apply) $0.50 $1.00 $3.50 $3.50 $5.00 $3.00 Call Waiting ID (Must have Calling Name and/or Number Delivery) Voice Mail (Must have Touch Tone & CF Busy or CF No Answer) Basic Package (10 2 min. each / 5 day memory) Enhanced Package (20 2 min. each / 10 day memory) $4.95 $8.95 Residential and Business Find Me Ring $5.95 Voice Mail/ $5.95 5

6 Please select the long distance company you would like to handle your 1+ long distance calls inside the Bryan LATA (IntraLATA calls) and your 1+ long distance calls outside the Bryan LATA (InterLATA calls). You must contact your carrier(s) at the number provided and make the necessary arrangements to insure proper billing. CARRIER NAMES AND CONTACT NUMBERS RESIDENTIAL AND BUSINESS IntraLATA InterLATA IntraLATA InterLATA 0333 Sprint Dial 1 Service 0288 AT&T Communications RES: RES: BUS: BUS: Colorado Valley Long Distance 0070 U.S. Long Distance, Inc. RES & BUS: RES & BUS: MCI Communications Service, Inc NTS Communications, Inc. RES: RES: BUS: BUS: WilTel Communications, LLC 0555 MCI Communications Services RES & BUS: RES & BUS: Colorado Valley Telephone Coop., Inc.* *Available for IntraLATA Only RES & BUS: Qwest Communications 0780 Matrix Telecom RES: RES: BUS: BUS: NTS Communications, Inc Primus Telecommunications, Inc. RES & BUS: BUS: Verizon Select Services, Inc Telco Communications Group RES: RES: BUS: BUS: SBC Long Distance 0444 Global Crossing Tele., Inc RES & BUS: RES: I will make the necessary arrangements with the long distance carrier(s) selected above. Applicant Signature Date Telephone Number Rate Plan (if applicable) 6

7 PREFERRED CARRIER FREEZE AUTHORIZATION Applicant Billing Name Applicant Mailing Address Telephone Number(s) For verification purposes, please provide either the Applicant s month and year of birth, mother s maiden name or last four digits of the Applicant s social security number. The purpose of this freeze is to prevent a change in your long distance service provider(s) without your consent. A freeze is a protection against slamming (switching your service provider(s) without your permission). You can impose a freeze on either your intralata (local toll) or interlata (long distance) service provider, or both. If you choose to freeze your account, you must contact Colorado Valley Telephone Cooperative, Inc. at (979) or (800) Colorado Valley must verify your freeze request by getting your written and signed authorization. You will not be able to change your long distance service provider without lifting the freeze. You may lift the freeze by giving Colorado Valley a written and signed request or by calling Colorado Valley with your request. You must do this in addition to providing the verification information that your new long distance service provider will request. There is no charge to the Applicant for imposing or lifting a freeze. Please complete the following for each service for which you are requesting a freeze: I authorize a freeze for the telephone number(s) listed above for intralata (local toll) service. Current preferred intralata (local toll) company Applicant Signature Date Applicant Printed Name I authorize a freeze for the telephone number(s) listed above for interlata (long distance) service. Current preferred interlata (long distance) company Applicant Signature Date Applicant Printed Name 7

8 APPLICATION FOR MEMBERSHIP AND CONTRACT FOR TELEPHONE SERVICE Legal Name of Applicant Service Address City, State & Zip Code The undersigned (hereinafter called the Applicant) hereby applies for membership in and agrees to take continuous telephone service from Colorado Valley Telephone Cooperative, Inc. (hereinafter called Cooperative), upon the following terms and conditions: 1. The Applicant will, when service becomes available, take from the Cooperative, telephone service to be used on the premises described in the Service Information on the Application for Telephone Service form and will pay monthly at the rate established by the Cooperative, it being expressly understood that the amounts paid by the Applicant in excess of operating costs and expenses of the Cooperative are furnished as capital and the Applicant shall be credited with the capital furnished as provided in the By-laws of the Cooperative. 2. The Applicant grants to the Cooperative the right to operate and maintain the existing telecommunications facilities in the present location and route on and across Applicant s land to Applicant s service location; and for a new service location, the additional right to install such facilities on a mutually agreeable location and route. 3. The Applicant will comply with and 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. 4. 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. The acceptance of this application for membership by the Cooperative, shall constitute a contract between the Applicant and the Cooperative, and upon establishment of service shall continue in force until canceled by written notice by either party to the other. Applicant Signature Applicant Printed Name Date Signed 8

9 EXPRESSNET DSL If you chose one of the Residential Bundled Packages on page 4 of this application, there is no need to complete the Monthly Charge Section on this page. Will this service also be used for gaming and/or security cameras? INFORMATION E addresses are limited to 256 characters Passwords require a minimum of 8 and a maximum of 16 characters. #1 #2 #3* Password Password Password *There is a charge for more than 5 addresses for EXPRESSNET DSL. Disconnection of your DSL service will result in termination of accounts associated with the service. MONTHLY CHARGES and/or OTHER CHARGES EXPRESSNET 1.5 Mbps Bus/Res $ Mbps w/uld Res Only ** $67.95 Static IP Address $ Mbps Bus/Res $47.95 Full Throttle Bus/Res* $87.95 Wireless Router Service $ Mbps Bus/Res $57.95 Additional Internet Hot Spot Service $27.95 UPS (one time charge) $54.95 *Full Throttle is offered to residential customers and small businesses only and includes wireless router service. **Unlimited Long Distance (ULD) is available exclusively to residential customers. ACTIVATION CHARGES Activate With 6 Month Contract $ $3.98 tax = $62.98 (Not applicable if external installation is required) Activate With 6 Month Contract $ $ 6.69 tax = $ Activate With No Contract $ $13.43 tax = $ Applicable Taxes have been added to Activation Charges. TERMS AND CONDITIONS By signing below, I agree to the following statements: - I am eighteen years old or older and all information supplied by or about me is accurate. - I have read and agree with the terms and conditions described in Colorado Valley Communications, Inc. (CVC) Internet Access Service Agreement. - When ordering DSL service, I authorize Colorado Valley Telephone Cooperative, Inc. to provision DSL service over my existing telephone line. (Not applicable when ordering Wireless service). - When ordering EXPRESSNET w/uld, I agree to abide to the terms and conditions described in CVC s unlimited long distance calling Terms and Conditions Policy. - I agree that any additional equipment furnished by CVC in conjunction with this service remains the property of CVC and shall be returned to CVC upon disconnection of service. A fee will be charged if equipment is not returned. - I agree that the Activation Fee includes standard installation of my DSL connection. Any additional work requested by me and performed by CVC will be billed at the hourly rate of $75.00 per hour. Applicant Signature Date 9

10 EXPRESSNET HIGH-SPEED INTERNET SERVICE COMMITMENT CONTRACT In order to receive the discounted Activation Fee when subscribing to EXPRESSNET High-Speed Internet service (EXPRESSNET), the Applicant must understand and agree to the following: You, the Applicant, agree to subscribe to Colorado Valley Communications, Inc. s (CVC) EXPRESSNET for a minimum of six (6) months from the date of activation of the service. In the event that you terminate your EXPRESSNET before completing six (6) consecutive months of service or if CVC terminates your service for nonpayment or other default before the end of the 6-month Service Commitment, you hereby agree to pay CVC a Termination Fee in the amount of $ in addition to all other amounts owed. EXPRESSNET customers with a 6-month Service Commitment who move to a new location before fulfilling their Service Commitment can have their EXPRESSNET transferred to the new location. A $25.00 Processing Fee and a $75.00 Move Charge are applicable to the Applicant at the time of the move. If the Applicant signs a new Service Commitment for an additional six (6) month period, the $75.00 Move Charge will be waived. Upon completion of your 6-month Service Commitment, your EXPRESSNET is provided on a month-to-month basis. No Termination Fee will be charged for the termination of service provided on a month-to-month basis. In the event that the telephone line associated with the EXPRESSNET DSL is disconnected for any reason including nonpayment, the EXPRESSNET DSL is terminated as well. If, at the end of three (3) months, the telephone line associated with the EXPRESSNET DSL is not reconnected, the EXPRESSNET DSL is considered permanently disconnected and the Termination Fee of $ applies. This section does not apply to EXPRESSNET Wireless service. Yes No I agree to the terms and conditions in the Service Commitment Contract and wish to execute said contract. I do not wish to execute the Service Commitment Contract. Applicant Printed Name Applicant Signature Date CVC Representative 10