CUSTOMER INFORMATION Name*  
                            
                            
                                                    First 
                                                 
                            
                            
                                                    Last 
                                                 
                            
                        
 
May we send you Text Messages?*   
Service Address*  Often times your home address, and where you plan to receive service.
    
                    Mailing/Billing Address Alternate Mailing/Billing Address*      
                    
SERVICE INFORMATION 
Centerville & Viborg Service For What Services Are You Applying?*  
Telephone Options 
Installation $16.50, plus $20 first month service. Renters include $50.00 deposit.Long Distance Service?*  Long Distance Options*  Please select your preference for long distance
Fort Randall Basic includes: 
Directory Status*  Please select your directory status. No charge.
Inside Wire Maintenance?*  Select Features 
Would you like the option to accept: Collect Calls*  Third Party Charges*  
Tripp & Parkston Service For What Services Are You Applying?*  Cable Television Installation $29.95
Channel Packages Movie Packages Starz/Encore Multiplex  w/additional Multiplex is $7.95
Atkinson Service For What Services Are You Applying?*  Cable Television Installation $29.95
Channel Packages Movie Packages Starz/Encore Multiplex  w/additional Multiplex is $7.95
Wagner, Lake Andes, Tyndall & Tabor Service For What Services Are You Applying?*  
Television Options 
Installation $29.95Channel Packages Movie Packages Starz/Encore Multiplex  w/additional Multiplex is $7.95
Telephone Options 
Installation $16.50, plus $20 first month service. Renters include $50.00 deposit.Long Distance Service?*  Long Distance Options*  Please select your preference for long distance
Fort Randall Basic includes: 
Directory Status*  Please select your directory status. No charge.
Inside Wire Maintenance?*  Select Features 
Would you like the option to accept: Collect Calls*  Third Party Charges*  
CUSTOMER CREDIT HISTORY Would you like information regarding the Automatic Payment Plan? Customer's Previous Address*      
                    Employer Address     
                    
CREDIT REFERENCES 
Bank Reference Bank Address     
                    Type of Account 
Trade Reference 
A company where you have established credit: utilities, home loan, car, college loan, etc.Company Address     
                    
TERMS OF AGREEMENT 
Electronic Signature Application By selecting the "I Accept" button, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Application. By selecting "I Accept" you consent to be legally bound by this Application's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing.