Application Form

August 28, 2018 TSC

"*" indicates required fields

Customer Information

Requested Date of Installation*

Name*

First Last

Phone*

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

May we send you Text Messages?*

Yes

Mobile Phone*

Please provide mobile phone capable of receiving messages.

Service Address*

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*

Street Address P.O. Box City State ZIP Code

Do You Rent or Own Your Home?*

Landlords Name*

Service Information

What Services Are You Applying For?*

Telephone

Internet

Internet Speed*

Speeds are in Mbps Down x Up

Asynchronous
25x3 Mbps (city limits only)	$49.95
50x5 Mbps	$59.95
100x20 Mbps	$75.00
Synchronous
100 Mbps	$90.00
250 Mbps	$150.00
500 Mbps	$240.00
1000 Mbps	$345.00

Some conditions apply, not all products, speeds, and services may be available in all areas. One of our friendly CSRs will verify your address and confirm available service options for your location before contacting you. Speeds and pricing are subject to change.

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

Credit Information

Would you like information regarding the Automatic Payment Plan?

Yes

Date of Birth*

Driver's License or ID Number*

Employment Status*

Employeed

Retired

If you are retired, please indicate as such; otherwise, please provide your current employment information.

Current Employer*

Employer Phone*

Employer Address

Street Address Address Line 2 City State ZIP Code

How long have you worked for this company?*

Terms & Agreement

The above information is correct and is given for the purpose of obtaining credit. Starbuck 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 Starbuck 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 Starbuck 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.