Western Iowa Telephone

Internet Application for Dial Up or High Speed DSL

Name:
Business Name (if applicable)
Address
City:
State:
Zip:
Home Phone:
Daytime Phone:
Billing Address (if different):

Primary e-mail (15 Characters maximum)

Additional e-mail #1 Real Name

Additional e-mail #2 Real Name

Additional e-mail #3 Real Name

Additional e-mail #4 Real Name

Mother's Maiden Name: (Needed for password security)

Please indicate system type: (ex. - Win2000, Win95, XP)

Choose which service you would like:

Dial-Up for $15.95/month for Telephone customers

Anthon & Onawa Dial-Up for $19.95/month

Accelerator first month is a free trial; $3/month thereafter

No activiation charges. (800 number access available through netINS) (A $50 cash deposit may be required based on credit history)

No activation charges.

No Activation charge for Accelerator.

SecureIT free trial for first month; $7.95/month thereafter.

No Activation charge for SecureIT Antivirus protection. Additional computers may be covered for just $5/month. Write the number of services you need in the box.

Basic DSL for $39.95/month(with phone service) with speeds up to 1.5 Mbp.

Basic DSL without phone service for $64.95/month.

Premier DSL for $49.95/month with speeds
up to 3 Mbps.

Business DSL for $79.95/month with speeds up to 4 Mbps downstream & 2 Mbps upstream.

No activation charges. External modem is provided at no additional charge, but the modem remains the property of Western Iowa Telephone and must be returned if DSL is disconnected for any reason.. (This service is available for members only. Prices and availability are subject to change without notice. All charges are subject to taxes and Federal Universal Service Charges.)
Contact our customer service reps for pricing on activation charges for all three levels of DSL service without telephone service.

No activation charges.

Do you currently have a WITA dial-up account?	Yes	No
If your answer is yes, would you like to keep dial-up access for $10.00 per month?	Yes	No
Do you have a 2nd line you wish to disconnect once DSL is in?	Yes	No
I have a 2nd line, but I wish to keep it for a teen line.	Yes	No
If you wish to disconnect this 2nd line, what is the telephone number?
Do you have either a 10 base-T Ethernet adapter or Network Card?(Service will not work without it)	Yes	No
Do you need a new jack installed near your computer? (If so, additional charges will apply)	Yes	No
Do you need a static IP address for a one-time charge of $50?	Yes	No

Your Signature:

By signing this application, I am agree to keep this DSL service for a minimum of 12 months. Charges may apply if service is disconnected prior to the end of the 12-month period.

Date: