APPLICATION FOR MEMBERSHIP AND COMMUNICATION SERVICE

Transcription

1 APPLICATION FOR MEMBERSHIP AND COMMUNICATION SERVICE The undersigned (hereinafter called the Applicant must be at least 18 years old to apply), hereby subscribes to membership in a corporation, organized under the laws of the State of South Dakota under the name of Valley Telecommunications Cooperative Associations, Inc. (hereinafter called the Cooperative ), for the purposed of furnishing communication service, upon the following terms and conditions: The Applicant must meet all conditions set forth in the Articles of Incorporation and by-laws of the Cooperative (found in the official telephone directory of the Cooperative) and pay any installation charges or required deposits. The Applicant will, when communication service becomes available, take from the Cooperative, communication service to be used on the premises described below and will pay thereafter the monthly rates as determined by the Board of Directors in accordance with established tariffs. The Applicant hereby grants to the Cooperative an easement to construct, operate and maintain a communication line or system on, over, or under the land described below and in or upon all streets, roads or highways abutting said land. Applicant hereby grants to the Cooperative access to the premises of Applicant at all reasonable times for its purpose of installing, repairing, maintaining, or removing any service to the premise. The Applicant will comply with and be bound by the provisions of the Articles of Incorporation and by-laws of the Cooperative, and such rules and regulations that may be adopted by the Cooperative. NOTE: All fields are required. If you do not provide the required information on this application, your request for service may be returned without action and/or your services may be delayed. APPLICANT: (Responsible for the account) (required) Congratulations! You will be a member of our cooperative. Capital Credit checks and credits are made payable to the applicant(s) listed below. Resident or Business Name: Resident Co-Applicant: Business Owner(s): Federal Tax ID #: Applicant: Co-Applicant: Birth Date: (required) Social Security #: (required) Daytime Contact #: Mobile/Cell #: Please Note: The only person(s) authorized to make changes to service(s) on this account is/are the applicant(s) listed above. If you wish for another party to make changes on your behalf (Example: spouse, POA, relative, caregiver), please indicate your wishes below. Any charges asa a result of changes to this account will be the responsibility of the subscriber to which the account belongs. (No minors will be allowed to make changes regardless of subscriber request.) AUTHORIZED ACCOUNT REPRESENTATIVE: RELATIONSHIP: CPNI ACCOUNT PASSWORD: To protect the privacy of your account, the FCC has implemented rules, which require you to provide a secure password when accessing information on your account. You will be required to provide this information whenever you call our office to discuss your account. Your password may be at least 4, but no more than 10 characters (numbers and/or letters). (required) CPNI Password: INSTALLATION/CREDIT INFORMATION: (required) Date for service to be connected (Monday-Friday) Address Service Requested at: E911 Physical Address City SD State Zip Code Billing Address (if different): PO Box or Postal Delivery Address City State Zip Code Have you previously had service with Valley Telecommunications Cooperative? If yes, when/where? Will you be providing us with a credit reference or deposit(s)? If you have had telephone service within the past 6 months, please contact your previous service provider for a credit reference and have the credit information sent to our business office. If you cannot provide credit information, a 45 deposit per service type will be required. Service will not be connected until the credit reference or deposits have been received in our business office. The deposits will be kept on file for 12 months or until an acceptable credit history has been established. 102 Main St S - PO Box 7 - Herreid, SD Phone (605) ~ Fax (605)

2 Phone I DO NOT wish to connect telephone service at this time. DIRECTORY LISTING INFORMATION: Published - Will print in the telephone directory and may be given out by the operator. Non-Published - Not printed in the telephone directory and CANNOT be given by the operator. Non-Listed - Not printed in the telephone directory and CAN be given by the operator Please list your name as it should appear in the directory: LINE RESTRICTIONS: The following line restrictions are available at no additional charge. Block Collect AND 3rd Number Bill Calls Block 3rd Number Bill Calls ONLY Block Collect Calls ONLY Block 900 Number Calls NONE OF THE ABOVE LONG DISTANCE CARRIERS: You must choose a long distance carrier from the enclosed pickable carrier list, or indicate below if you do not wish to subscribe to long distance service. Valley Telecommunications Calls Within South Dakota Intra-Lata Carrier: Calls Out-of-State Inter-Late Carrier: I DO NOT wish to subscribe to Long Distance Service at this time. Mandatory Charges Dial Tone Plus Fees: E911 Surcharge, Communications Impaired Fund, Broadband Voice Switching Fee & ATA Lease (7.70) Additional Dial Tone Plus Fees: E911 Surcharge, Communications Impaired Fund, Broadband Voice Switching Fee & ATA Lease (7.70) Additional Dial Tone Plus Fees: E911 Surcharge, Communications Impaired Fund, Broadband Voice Switching Fee & ATA Lease (7.70) Popular Calling Features Anonymous Call Rejection Reject calls where the caller has deliberately blocked their number from delivery Allows you to receive a second call when you are on the phone with someone else. Call Waiting/Cancel Call Waiting 1.00 Can use a deactivation code to disable call waiting prior to placing a call if you do not want to be interrupted. Automatically transfer incoming calls to another telephone number. Call Forwarding 1.00 **Long distance charges apply** **Many additional features are available upon request including: Auto Callback, Auto Recall (*69), Call Forward Busy, Call Forward/Don t Answer, Warm Line, Selective Call Forward, Selective Call Acceptance, Selective Call Rejection, 3 Way Calling, Distinctive Ring, 30 Number Speed Calling, 8 Number Speed Calling, Sim Ring, Notify Plus) Premium Calling Features **Choose Caller ID & Call Waiting and receive Call Waiting ID FREE** Caller ID Name & Number Delivery 5.00 **Caller ID is included for FREE with all of our Video TV packages.** Voice Mail - Bronze Package 1 Mailbox with 5 minutes of storage 3.00 Voice Mail - Silver Package 3 Mailboxes with 10 minutes of storage PLUS E-Forward Messaging, Phone Central Interface & Valley Video Message Indicator. E-Forward Address: 4.00 Voice Mail - Gold Package 5 Mailboxes with 20 minutes of storage PLUS E-Forward Messaging, Phone Central Interface, Valley Video Message Indicator & Out-Dial Feature. E-Forward Address: 5.00 Telemarketer Call Screening Intercepts telemarketer calls before the phone even rings and announces that the customer does not accept calls from telemarketers Value Line Distinctive Ring option for use with Fax Machines, etc **Many additional features are available upon request including: Conference Calling, Directory Number Hunt, Call Logging, Notify Plus, Hunt Group Queuing, Deny Origination and Sim Ring Phone Total (Less Taxes):

3 Broadband I DO NOT wish to connect Broadband service at this time. 50M/50M 1-4 devices, mainly ing and surfing (must be accompanied by a phone service) (includes required managed wifi) M/100M 5-8 devices, multiple users streaming and downloading (must be accompanied by a phone service) (includes required managed wifi) M/250M 8+ devices simultaneously heavy streaming and gaming, medium sized businesses (includes required managed wifi) M/500M Medium to large businesses and extreme heavy home use. Advanced work-from-home applications, online surveillance, video streaming, etc. (includes required managed wifi) Gig (1000M/1000M) Great for homes and businesses that need it all (includes required managed wifi) Broadband Username/ Broadband Password: Must be between 8 and 13 numbers and letters - upper and lowercase. Password may not be the same as the username. Wifi Password (if applicable): Password to be used to secure your wireless connection. Managed Wifi Managed Wifi Let us easily manage your wireless internet service safely and securely in the cloud. *Eliminates the cost of a wireless router, no longer need to replace or upgrade your equipment, enables remote support and much, much more.* (Managed Wifi is required for all Broadband speeds) Included with all Broadband speeds Anti-Virus Protection SecureIT Live Anti-Virus, Firewall, Spyware, PopUp Blocker, Online Malware Blocker, Live 24/7 Support & More! Notification Anti-Virus, Firewall, Spyware, PopUp Blocker, Online Malware Blocker, Parental Controls, Content Filtering, Disk Defragmentation, SecureIT Plus 5.99 Live 24/7 Support & More! Notification Broadband Total (Less Taxes):

4 Digital TV I DO NOT wish to connect Digital TV service at this time. TV Packages Economy 27 Network Channels including local channels (Includes FREE Caller ID & FREE High Definition) Basic 105 Channels + 50 Music Channels (Includes FREE Caller ID & FREE High Definition) Expanded 148 Channels + 50 Music Channels (Includes FREE Caller ID & FREE High Definition) Retransmission Fee Retransmission fee on local channels (required) Premium Add-ons DVR Record your content digitally! Provides you the ability to watch your favorite programs when you want DVR Plus to on any TV in your house. Record up to10 programs at one time with up to 500GB of DVR storage! Restart/PLT (Pause Live TV) Restart a show that s already in progress and also have the capability to pause LIVE TV! 1.99 Caller ID for TV FREE (5.00 Value) High Definition FREE (11.99 Value) Record your content digitally! Provides you the ability to watch your favorite programs when you want to on any TV in your house. Record up to 5 programs at one time with up to 250GB of DVR storage! (DVR required unless accompanied by either phone or broadband service) FREE Caller ID on your phone and TV! Up to 71 Channels in crystal clear High Definition! Movie Channels ***Residential Only*** HBO Movie Package HBO, HBO Family, HBO Plus, HBO signature & HBO Comedy MAX Package Cinemax, MoreMax, Action Mac & Thriller Max Showtime Package Showtime, Showtime 2, Showtime Extreme, Showtime Family, The Movie Channel Starz & Encore Package Starz, Starz Theatre, Starz Cinema, Starz Family, Encore, Encore WAM True Stories, Mysteries, Love Stories, Action & Westerns Playboy TV NFL Redzone See every touchdown from every game! (Availabe from August-January) 7.99 VOD Video On Demand **some restrictions may apply** # of TV's to be Connected TV's Maximum of 3 TVs watching 3 different channels. **Additional streams are available for 7.99/per stream. (Must be accompanied by broadband or dial-tone to waive STB charge on first 3 TV's) Additional Streams 1st TV Additional STB & Remote (No Charge if accompanied by broadband or dial tone service, otherwise 7.99) 2nd TV Additional STB & Remote (No Charge if accompanied by broadband or dial tone service, otherwise 7.99) 3rd TV Additional STB & Remote (No Charge if accompanied by broadband or dial tone service, otherwise 7.99) 4th TV Additional STB & Remote th TV Additional STB & Remote th TV Additional STB & Remote 7.99 Digital TV Total (Less Taxes):

5 Total Maintenance Plans Single Service Plan Telephone, Broadband or Video TV Coverage 2.00 Double Service Plan Telephone, Broadband or Video TV Coverage 3.50 Triple Service Plan Telephone, Broadband and Video TV Coverage 5.00 No Maintenance Plan Do not wish to subscribe to any Total Maintenance Plans at this time Member Loyalty Discounts Triple Play Services A monthly discount for having 3 of Valley s services (does not include Security & Monitoring) ****Residential Only**** Quad Play Services A monthly discount for having 4 of Valley s services (does not include Security & Monitoring) ****Residential Only**** Multi-Tier Discounts Must subscribe to 3+ services above to qualify! 250M/250M Broadband A monthly discount for having at least 3 of Valley s services and having 250M/250M Broadband M/500M Broadband A monthly discount for having at least 3 of Valley s services and having 500M/500M Broadband Gig (1000M/1000M Broadband) A monthly discount for having at least 3 of Valley s services and having 1 Gig (1000M/1000M) Broadband Total Maintenance & Discounts (Less Taxes): Total Discounts: Total Monthly Order (Less Taxes): Deposits Telephone Deposit Broadband Deposit Digital TV Deposit Prepayment Due 100 Prepayment To Go Towards 1st Month s Bill Total Due Before Installation E-bill Switch your account to paperless billing and receive a ONE time 10 credit. You'll receive your monthly bills from us electornically and pay them electronically. Must subscribe to our broadband service to qualify! Go green and save green! Yes, I would like to sign up for e-bill and receive my bill by ! address: Password: 24 Month Agreements Valley Telecommunications Cooperative Association, Inc. ( Valley ) is pleased to provide you with Voice, Digital TV, and/or Broadband Service. This document contains the agreement ( Agreement ) between you, the customer ( Customer ) and Valley. Your obligation with Valley is for the services indicated in this Agreement, which carries a 24 month term. Cancellation of any service before the end of the minimum term is subject to termination fees, which includes all waived charges indicated in this Agreement, as well as obligations detailed in Valley s Terms and Conditions. Customer further agrees to Valley s Terms and Conditions in its entirety, including Valley s Acceptable Use Policy. A copy of the Terms and Conditions is available on Valley s website, and also available in hard copy upon request. Yes, I would like to sign a 24 month term agreement to waive the following installation fees. No, I do not want to sign a 24 month term agreement and agree to pay the following installation fees. Applicant Signature: Date: Printed Name: Co-Applicant Signature: Date: Printed Name:

6 E=Economy Package B=Basic Package EX=Expanded Basic Channel Name Channel E B EX Channel Name Channel E Local Channel/Alerts 2 Crime & Investigation 83 CBS-KDLO HD SD 3 DIY 85 CW-KSFY 4 Food Network HD 86 NBC-KFYR HD ND 5 HGTV HD 87 ME TV 6 TLC HD 88 SD Public HD KCSD 7 Discovery HD 89 NBC-KDLT HD SD 8 OWN 90 ABC-KABY HD SD 9 Travel Channel HD 91 My UTV 10 Destination America HD 92 The Weather Channel 11 ID HD 93 CBS-KXMB HD ND 12 Science Channel HD 94 HSN 13 American Heroes 95 QVC 14 BBC America 96 Jewelry TV 15 RFD TV HD 97 FOX-KTTW HD SD 16 A&E HD 98 This TV-KTTW 17 History Channel HD 99 KCPO - Central Plains 18 FYI HD 100 KELO Weather Now 19 Viceland HD 101 Weather Info 20 National Geographic 102 Evine LIVE 21 Animal Planet HD 103 Antenna TV 22 SDPB2 World 104 The Cowboy Channel 23 SDPB3 Create 105 MLB Network HD 24 Discovery Life 106 ESPN HD 25 Cooking Channel 108 ESPN2 HD 26 National Geographic Wild 109 ESPN Classic 27 Discovery Family HD 110 ESPNU HD 28 Disney Channel HD 111 ESPN News HD 29 Disney XD HD 112 NFL Network HD 30 Nickelodeon HD 113 Golf Channel HD 31 Nick Jr 114 Big 10 Network HD 32 Nicktoons 115 Big 10 Network 2 HD 33 Teen NICK 116 Big 10 Network 3 HD 34 Cartoon Network HD 117 FOX Sports North Plus 35 Disney Jr HD 118 FOX Sports 1 HD 36 PBS Sprout 119 Sportsman Channel 37 Boomerang 120 NBC Sports Network HD 38 MTV HD 122 FOX Sports North HD 39 GAC 123 Outdoor Channel HD 40 MTV2 124 CBS Sports Network 41 Nick Music 125 Midco Sports Network HD 42 MTV Classics 126 Tennis Channel HD 43 CMT Pure Country 127 FOX College - Atlantic 44 VH1 Music First HD 128 FOX College-Central 45 CMT HD 129 FOX College-Pacific 46 Fuse 130 Olympic Channel 47 Velocity HD 136 FOX Sports 2 HD 48 AXS TV HD 137 SEC Network HD 49 HDNet Movies HD 138 FX Movie Channel 50 CNN HD 140 Lifetime HD 51 HLN HD 141 Lifetime Movie Network HD 52 CNBC HD 142 Lifetime Real Women 53 FOX News Channel HD 143 WE 54 Fusion HD 144 FXX HD 55 TRU TV HD 145 Oxygen HD 56 MSNBC HD 146 FX HD 57 CSPAN 147 TNT HD 58 CSPAN2 148 Paramount HD (Prev. Spike) 59 CNBC World 149 Comedy Central HD 60 FOX Business Network HD 150 Bravo HD 62 CSPAN Freeform HD 64 BBC World News 152 USA HD 65 The Blaze HD 153 TBS HD 66 Sioux Falls Christian KSCB 160 WGN HD 67 TBN 161 TVLand HD 68 EWTN 162 GSN 69 Inspiration 163 E! HD 70 COZI TV (KTTW) 164 SyFy HD 71 PPV Special Events Escape 72 Valley Local Content 290 TCM HD 73 Special Events AMC HD 74 Special Events Hallmark HD 75 Special Events Hallmark Movies & Mysteries 76 Special Events Military History 82 Valley TV Tutorials 999 B EX 61.99