Application Form – Fort Randall Telephone Co.

CUSTOMER INFORMATION

Requested Date of Installation*

Name*

First Last

Business Name (if applicable):

Phone*

If you'd like a copy of your form, please provide a valid email.

May we send you Text Messages?*

Yes

Mobile Phone*

Please provide mobile phone capable of receiving messages.

Service Address*

Often times your home address, and where you plan to receive service.

Street Address P.O. Box City State ZIP Code

Mailing/Billing Address

Same as Service Address

Alternate Mailing/Billing Address*

Street Address P.O. Box City State ZIP Code

Do You Rent or Own Your Home?*

Landlords Name*

Other adults over the age of 18 at this address?*

Please provide their names*

SERVICE INFORMATION

Service Area*

Please select your local Fort Randall Telephone Company location

Centerville & Viborg Service

For What Services Are You Applying?*

Internet

Telephone

Internet Options

High-Speed Internet, up to 25 mbps $52.95 includes modem (not available in all areas)
High-Speed Internet, up to 50 mbps $64.95 includes modem (not available in all areas)
High-Speed Internet, up to 100 mbps $80.00 includes modem (not available in all areas)
Installation $79.95

Some conditions apply, not all products, speeds, and services may be available in all areas. One of our friendly CSRs will verify your address and confirm available service options for your location before contacting you. Speeds and pricing are subject to change.

Username*

Telephone Options

Installation $16.50, plus $20 first month service. Renters include $50.00 deposit.

Long Distance Service?*

Yes

Long Distance Options*

Please select your preference for long distance

Fort Randall Basic (No Monthly Fee)

$4.95/mo and .07 Minute Plan

$14.95 Unlimited 5000 Minute Plan

$25.00 Business Unlimited 5000 Minute Plan

Another Provider

Fort Randall Basic includes:
.15 per minute out of SD
.23 per minute in SD (8-6pm M-F)
and .11 per minute after 6pm and weekends.

Long Distance Provider*

Which long distance company do you prefer?

Directory Status*

Please select your directory status. No charge.

Published

Unpublished

Inside Wire Maintenance?*

Yes ($1.95/mo)

Select Features

Call Waiting ($5.00/mo)

Caller ID ($5.95/mo Residential, $7.95/mo Business)

Voicemail ($3.95/mo Residential, $6.95/mo Business)

Would you like the option to accept:

Collect Calls*

Yes

Third Party Charges*

Yes

Tripp & Parkston Service

For What Services Are You Applying?*

Internet

Television

Internet Options

Cable Internet Within City Limits $51.95, Installation $29.95

Username*

Cable Television Installation $29.95

Channel Packages

Basic Package (Ch 2-78) $126.95

Limited Basic (Ch 2-22) $66.76

DVR $10.95

Digital Package (Ch 201-275) $9.00

HD Package (Ch 700-779) $4.25

Movie Packages

HBO Multiplex $11.95

Cinemax Multiplex $11.95

Showtime/TMC Multiplex $11.95

Starz/Encore Multiplex $12.95

HBO/Cinemax Multiplex $15.95

Starz/Encore Multiplex w/additional Multiplex is $7.95

Atkinson Service

For What Services Are You Applying?*

Internet

Television

Internet Options

Cable Internet Within City Limits $51.95, Installation $29.95

Username*

Cable Television Installation $29.95

Channel Packages

Basic Package (Ch 2-78) $124.33

Limited Basic (Ch 2-22) $66.82

DVR $10.95

Digital Package (Ch 201-275) $9.00

HD Package (Ch 700-779) $4.25

Movie Packages

HBO Multiplex $11.95

Cinemax Multiplex $11.95

Showtime/TMC Multiplex $11.95

Starz/Encore Multiplex $12.95

HBO/Cinemax Multiplex $15.95

Starz/Encore Multiplex w/additional Multiplex is $7.95

Wagner, Lake Andes, Tyndall & Tabor Service

For What Services Are You Applying?*

Internet

Television

Telephone

Internet Options

Username*

Television Options

Installation $29.95

Channel Packages

Basic Package (Ch 2-78) $126.95

Limited Basic (Ch 2-22) $66.76

DVR $10.95

Digital Package (Ch 201-275) $9.00

HD Package (Ch 700-779) $4.25

Movie Packages

HBO Multiplex $11.95

Cinemax Multiplex $11.95

Showtime/TMC Multiplex $11.95

Starz/Encore Multiplex $12.95

HBO/Cinemax Multiplex $15.95

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?*

Yes

Long Distance Options*

Please select your preference for long distance

Fort Randall Basic (No Monthly Fee)

$4.95/mo and .07 Minute Plan

$14.95 Unlimited 5000 Minute Plan

Another Provider

Fort Randall Basic includes:
.15 per minute out of SD
.23 per minute in SD (8-6pm M-F)
and .11 per minute after 6pm and weekends.

Long Distance Provider*

Which long distance company do you prefer?

Directory Status*

Please select your directory status. No charge.

Published

Unpublished

Inside Wire Maintenance?*

Yes

Select Features

Call Waiting ($5.00/mo)

Caller ID ($5.95/mo)

Voicemail ($3.95/mo Res | $6.95/mo Bus)

Would you like the option to accept:

Collect Calls*

Yes

Third Party Charges*

Yes

CUSTOMER CREDIT HISTORY

Would you like information regarding the Automatic Payment Plan?

Yes

Customer's Previous Phone Number*

Customer's Previous Address*

Street Address City State ZIP Code

How long were you at the above previous address?*

Date of Birth*

Current Employer*

Employer Phone*

Employer Address

Street Address City State ZIP Code

How long have you worked for this company?*

The above information is correct and is given for the purpose of obtaining credit. Fort Randall Telephone Company is authorized to verify this information and to obtain additional information in reviewing this credit request.

I hereby agree to the rules and regulations of Fort Randall Telephone Company as set forth in its exchange tariff, and to any general changes in rules, or rates for these services furnished under this application. This application becomes a contract when accepted by Fort Randall Telephone Company.

CREDIT REFERENCES

Bank Reference

Bank Name

Bank Phone Number

Bank Address

Street Address City State ZIP Code

Type of Account

Checking

Savings

Trade Reference

A company where you have established credit: utilities, home loan, car, college loan, etc.

Company Name

Company Phone Number

Company Address

Street Address City State ZIP Code

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.