Billing Address if different

Social Security Number:His

Hers

Service Location (who lived there?)

What is your race? (opt)

Previous Address

Previous Telephone Company

Previous telephone number

Where do you bank?

Any equipment left at new residence?

Would you like to block collect calls? Would you like to block 3^rd number billed calls?

Would you like to block 900 calls?

Which long distance company would you like?

(If  no carrier is selected, we will assign a carrier to you.)If choosing Western Iowa Long Distance, please indicate whichplan you would like to be on.

Please list any other instructions or comments

Present Employer

Employer's Address

Spouse’s Employer

Employer's Address

Name, Address and Phone Number of 2 close friends or relatives :  

1. Name

Address

Phone Number

2.   Name

Address

Phone Number

Do you want your number listed in the telephone book?

($1.00 monthly charge not to have it published.)

I understand there is a charge for this service of $1.00 per month.  (This charge is subject to change.)

Western Iowa Telephone Association is not responsible for losses arising from having a Non-Published number.  I also understand that my telephone number will not be listed either in the telephone directory or with information services.  Unless the specific call number is given by the person calling, connection will not be established with a telephone having a “non-published” number. 

Western Iowa Telephone Association is not responsible for anyone obtaining this telephone number from other sources; however, all reasonable effort will be made to keep this number confidential.

I understand that my number WILL BE DISPLAYED to other customers who have Caller ID, unless I use per call blocking (free-*67) or subscribe to per line blocking at a charge of $1.00 per month.  (This charge is subject to change.)

WOULD YOU LIKE THE PER LINE BLOCKING FOR $1.00 PER MONTH?  YES     NO (check one)

CREDIT POLICY:  Our bills go out on the 1^st of the month and are DUE BY THE 20^TH OF THE MONTH.  Any payments received after the 20^th of the month are considered delinquent and an additional charge of 1.5% of the total bill will be added to the total of the bill.  Accounts that remain unpaid on the 3rd of the month after 4:30 p.m. (irregardless of weekends and holidays) following the previous billing month will have service suspended, allowing only calls to Emergency 911 until a reconnection fee of $25.00 plus tax, and the amount of the bill is paid.

Any account having a balance remaining after 90 days will be charged 1% compound interest unless specific arrangements have been made.

There will be a $20.00 charge for all returned checks.

SPECIAL DEPOSIT POLICY:  Special deposits are kept for a minimum of 1 year.  An interest rate of  3% is paid on all special deposits.  The deposit will be returned only after 1 year of prompt payments made before the 20^th of each month, or after an adequate amount of capital credits have been allocated to your account. 

After 1 year of prompt payments, you may request the return of your deposit, which will be credited to your telephone billing account.

If you discontinue service while we are holding a deposit, the deposit will be credited to your final bill.  If there is a credit balance, you will receive a check for the balance.

CHARGES (per line):   

All deposits MUST be in CASH CREDIT CARD or MONEY ORDER.

Call our office for the Total Amount to send (1-800-469-0811 or 712-944-5711)    

Please send payment with this application

*I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND AGREE TO ABIDE BY THE  INDICATIONS  

I HAVE MADE ON THIS APPLICATION.

Signature:

Date: