Application Form September 3, 2021 TSC Customer InformationRequested Date of Installation(Required) MM slash DD slash YYYY Name(Required) First Last Phone(Required)Email If you'd like a copy of your form, please provide a valid email.Service Address(Required)Often times your home address, and where you plan to receive service. Street Address P.O. Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing/Billing Address Same as Service Address Alternate Mailing/Billing Address(Required) Street Address P.O. Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do You Rent or Own Your Home?(Required)Please ChoseRentOwnLandlords Name(Required) Service InformationWhat Services Are You Applying For?(Required) Telephone Internet Select Internet Options Internet Pricing 25 Mbps$49.95 50 Mbps$59.95 100 Mbps$75.00 Internet SpeedPlease Select25 Mbps50 Mbps100 MbpsSpeeds are in Mbps Down x UpWiFi Password What would you like for your wifi password? It must be 8 characters or more.There may be a $50.00 deposit with the first month of service & installation charges if they apply!Select Telephone Options Long Distance Service? No Yes Long Distance Carrier?(Required) You may need to contact the long distance company to set up a calling plan suitable to your needs.Would you like your number Published? No Yes Permanent line blocking? No Yes Permanent line blocking prevents the display of your name and number at all times when you call someone who has caller identification. If you want to identify yourself for just one call, you will be required to press *82 before you dial the number. After you hang up, line blocking will resume.Please mark the features you would like: Call Waiting (additional $5.00 per month) Caller Identification (additional $5.95 per month) Voicemail (additional $6.95 per month) Option to Accept Collect Calls Option to Accept Third Party Charges Inside Wire Maintenance Inside Wire Maintenance includes an additional charge per month & certain restrictions apply.Credit InformationWould you like information regarding the Automatic Payment Plan? No Yes Date of Birth(Required) MM slash DD slash YYYY Current Employer(Required) Employer Phone(Required)Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you worked for this company?(Required) Driver's License or ID Number(Required) Terms & AgreementThe above information is correct and is given for the purpose of obtaining credit. Mt. Rushmore 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 Mt. Rushmore 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 Mt. Rushmore Telephone Company.Electronic Signature ApplicationBy 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.CAPTCHANameThis field is for validation purposes and should be left unchanged.