Application Form – Mt. Rushmore Telephone Co.

Customer Information

Requested Date of Installation(Required)

Name(Required)

First Last

Phone(Required)

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

May we send you Text Messages?(Required)

Yes

Mobile Phone(Required)

Please provide mobile phone capable of receiving messages.

Service Address(Required)

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(Required)

Street Address P.O. Box City State ZIP Code

Do You Rent or Own Your Home?(Required)

Landlords Name(Required)

Service Information

What 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 Speed

Speeds are in Mbps Down x Up

There may be a $50.00 deposit with the first month of service & installation charges if they apply!

Select Telephone Options

Long Distance Service?

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?

Yes

Permanent line blocking?

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 Information

Would you like information regarding the Automatic Payment Plan?

Yes

Date of Birth(Required)

Current Employer(Required)

Employer Phone(Required)

Employer Address

Street Address Address Line 2 City State ZIP Code

How long have you worked for this company?(Required)

Driver's License or ID Number(Required)

Terms & Agreement

The 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 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.

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Phone

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