Application for ServicePlease complete and submit the form below for service. A CTC representative will contact you with questions and/or to schedule service. Name * First Name Last Name E911 Address * Address, City, State & Zip Billing Address (if different than Service Address) Address, City, State & Zip Name in Directory How would you like to receive your bill? Email Paper via Mail Do you want your number to be unlisted? $1.00/mo charge for unlisted number Yes No Are you renting? Yes No Landlord's Name (if renting) Date Service Requested (Allow 2 business days) Current Home Phone (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Email Current Employer Name & Number I was referred to CTC by (Referrer will receive a $25 bill credit) Internet Service 100Mb - $75.95 250Mb - $109.95 500Mb - $169.95 1 Gig - $199.95 Internet Add-Ons Managed WiFi - $6.95 Managed WiFi Extender - $4.95 SecureIT Plus - $7.00 Phone Service Includes Unlimited Local Calling, Basic Voicemail & Caller ID. Unlimited Long Distance available in Williamsburg. Williamsburg Residential Phone - $24.00 Williamsburg Business Phone - $29.00 Guernsey, Hartwick, Ladora & Victor Residential Phone - $22.47 Guernsey, Hartwick, Ladora & Victor Business Phone - $22.47 Long Distance Service Options (only needed for customers in Guernsey, Hartwick, Ladora & Victor) Nationwide Calling Plans are $0.07/minute for interstate and intrastate calls. Overage charge is $0.10/minute per month. Minutes not used are not carried over to the next month. There is a one-time hookup charge of $14.00 for new CTC Long Distance customers and a $5.50 upgrade charge for existing CTC Long Distance plan customers. 14¢ One Rate Plan - Billed in 6-second blocks after 30 second minimum 10¢ Plan - 10¢/minute & $3.95/mo - Billed in 6-second blocks after 30 second minimum 100 Minutes - $7.00 250 Minutes - $17.50 500 Minutes - $35.00 1000 Minutes - $70.00 All prices shown are for Residential & Small Business customers only. Corporate/Enterprise customers, please call for a customized quote. *Prices shown do not include regulatory fees and taxes which may exceed $14 for phone service. Installation and activation fees may apply. All services may not be available in all areas. Internet speeds are “up to” and may vary. All fees are monthly unless stated as “one-time fees”. Upon disconnection equipment must be returned to our office. 3.5% Convenience Fee will be charged for all credit card payments. Customer Proprietary Network Information (CPNI) Keeping your information private is important to us. In keeping with the Customer Proprietary Network Information (CPNI) rules, we are asking that you provide the information below, so that we can confirm with whom we are speaking when you contact us by phone. Additionally, you may add other ‘authorized’ users to your account. They can be anyone that you wish, or those that need to have access, to make changes to your account with us. List Names You Wish to Have Access to Your Account Your Mother's Maiden Name * Your Favorite Color * Requested Password * Assistance Programs Financial assistance is available for eligible Iowans to help them afford basic telephone and/or broadband service thru Lifeline. Learn more at www.getinternet.gov Automatic Payments - I'm interested in setting up Automatic Payments from a Checking or Savings Account For security reasons, we require a physical signature and voided check. We will contact you to set this service up. Yes, I'm interested in Electronic Payments. Please contact me. No, I'm not interested in Electronic Payments at this time. Customer Compliance Agreement & Authorization (Signature Required - Please Type Your Name) * By establishing account with CTC Technology or using any software provided, developed, licensed or owned by CTC, I agree to be bound by this Agreement and to use the Services in compliance with this agreement and other CTC’s policies posted from time to time on CTC’s website at www.ctctechnology.net. I understand that all charges are listed on this application are monthly and do not include taxes and regulatory fees. I authorize CTC Technologies to install all appropriate equipment for the services I have requested. I understand that all policies and procedures can be found on CTC’s website or given upon request. All adults are required to sign this application. Thank you for your application. A Siyeh Representative will be on contact to schedule your installation and answer any questions you may have.
