Application for Telephone Service - Park Region Mutual Telephone Co. & Otter Tail Telcom

Application for Telephone Service

Complete and submit on-line or print out and mail to our office.

Applicant's Name:

Last

First

Middle

Service Location:

Township

Section

Range

Fire #

Billing Address:

County:

City:

State:

Zip:

Name of Person Previously Living at this Location:

Nearest Neighbor with Telephone Service:

Name & Address As You'll Like It to Appear in the Directory

Non-List
(Not Listed in phonebook)

Non-Pub
(Not listed in phonebook or directory assistance)

Consent to disclosure? Yes No

Class of Service:	Business Residential Seasonal
Seasonal Billing Address:
Date Service to be Installed:	(mm/dd/yy)
Do you need to purchase or rent any phone equipment from us?
Any Inside Wire Installation Required from us:	Wire Maintenance: Self Park Region (.25 per jack per month)

OPTIONS: (Please check your selections)

Repeat Dialing (2.25)	Call Screening (2.25)	Voice Mail (4.95) Residential	8# Speed Calling (package)
Call Return (2.25)	Call Trace (1.00 per trace)	Voice Mail (6.95) Business	30# Speed Calling (package)
Priority Ringing (2.25)	Caller ID (2.25)	Call Waiting (n/c)	900 Block (n/c)
Special Call Acceptance (2.25)	PRT Caller ID Unit (1.50)	Call Forwarding (n/c)	Internet 10hr (9.95)
Preferred Call Forwarding (2.25)	CPE Caller ID Unit	3-Way Calling (n/c)	Internet Unlimited (19.95)
			Pic Freeze (n/c)

Has applicant had previous service with Park Region? Yes No When?

Social Security #:
Civil Status:	Single Married
Spouse Name:

Your Previous Telephone #

Date Disconnected

Name of Telephone Company

City

State

Utility Reference:
Applicant grants permission to use credit reporting agency information should utility reference be unavailable. Yes No
Automatic Payment Plan:	Yes (Will need a voided check and completed form.)

Your Last Address

City

State

Where Employed

Work Tel. #

If unemployed, what type of assistance do you receive?

Other household wage earners?

In making this application, the undersigned agrees to the rules and regulations of the Telephone Company as set forth in the Exchange Tariff, and to any general changes in rules or rates for the service furnished under this application. This application becomes a contract when accepted in writing by the Telephone Company. If applicant's credit rating is not found to be satisfactory, a cash deposit will be required. The applicant does hereby agree that payment for the Telephone Service will be made within twenty days of issue of the Telephone Bill. In the event of default of payment, said Telephone Service will be subject to discontinuance without further notification.

I agree.

Subsidized accounts are available to customers meeting certain low-income criteria. Information concerning these plans is available from your Park Region Telephone representative at 1-800-247-2706 or 826-6161.

Notice Regarding Bill and Usage Related Information
In the course of providing service to you, we will possess certain billing and usage-related information about the quantity, type and destination of telecommunications services you use. You have a right, and we have a duty, to protect the confidentiality of this information. This information may be useful to tailor our products and services to your needs and to enhance our ability to meet all of your telecommunications needs. By checking the authorization box on this document, we will use your billing and usage-related information to offer you other Park Region Telephone products or services that may satisfy your needs and to respond to your concerns if you have become dissatisfied or cancel any of your services. Of course, your decision will not harm the quality of service provided, and we will honor your choice until you expressly tell us otherwise.

I authorize Park Region Telephone, its affiliates, or its agents, to use billing and usage information related to my account to see if I would benefit from other telecommunications services offered by Park Region Telephone, its affiliates, or its agents, and market them to me.

Signature

Date

** Subsidized discounts are available to customers meeting certain low-income criteria. Information concerning these plans is available from your Park Region Telephone representative at 1-800-247-2706 or 826-6161.