Residential Application for Service

Within the City of Wray

Plains Communication Services, LLC

29360 US Highway 34, Wray, Colorado 80758

(voice) 970-592-2211 (fax) 970-592-2212

(email) plains@plainstel.com (website) www.plainstel.com

Current Telephone Number *

Will you be moving an existing telephone number to Plains?

It's important that you don't disconnect any existing service until you have spoken with us. We’ll walk you through the process. If you want to keep your existing number to transfer (port) it to Plains for service, the number must be active. A disconnected number is not available for porting to Plains and will be lost. *

No

Yes Yes

Name of Applicant *

0/50 characters

Date of Birth *

Social Security # *

Drivers License State and # *

Service Address, City, State, Zip *

Mailing Address, City, State, Zip *

Previous Address, City, State, Zip *

Employer and Work Phone # *

Cell Phone # *

Nearest Relative Not Living with Applicant, Phone #, Address, Relationship to Applicant *

Everything that I have stated in this application is correct to the best of my knowledge. I authorize Plains Cooperative Telephone Association, Inc. to check my credit history with Online Utility Exchange and to answer future questions about its credit experience with me. (The amount of the deposit which may be required of an applicant for the purpose of establishing credit is $250-$500). Note: All personal information Plains Cooperative Telephone Assn. accumulates pertaining to your account is available to you, the applicant, at any time.

Plains Communication Services, LLC, service is for a minimum of 24 months following installation (i.e. the commitment period). If service is disconnected before the commitment period is complete, a $200 service charge will apply. A $25 late fee will be assessed when bill is 30 days past due.

Signature *

clear

Broadband Options and Charges

Non-Recurring Charges

Nonrecurring Standard Installation*

$

$149.95

*Additional charges may apply for a non-standard installation, based on your location. You will have the opportunity to approve any additonal charges.

Broadband Speeds, Rates, and Related Monthly Charges

10 Mbps download/ 5 Mbps upload (Includes Telephone)

25 Mbps download/10 Mbps upload

50 Mbps download/25 Mbps upload

100 Mbps download/50 Mbps upload

200 Mbps download/100 Mbps upload

500 Mbps download/100 Mbps upload

1 Gbps download/100 Mbps upload

1 Gbps download/1 Gbps upload

Router Lease & Repair/Replacement*

Recurring Monthly Cost *

* The router repair and replacement coverage will be void if we discover that the lease router has been altered by the customer and the customer will be billed for the retail price of the lease router.

In signing below, I acknowledge that I am entering into a 24-month commitment which begins after any promotional period ends. I understand that there will be a $200 Early Termination Fee if my Internet service is disconnected before the 24-month commitment is fulfilled.

Upon service deactivation, failure to return Provider-owned equipment such as Router or Plume Pod will also result in a fee charged to the customer.

Customers may call 1-970-358-4211 to speak with a customer service representative about Early Termination Fees in the event of service deactivation with the Provider.

I also understand that my wireless network will be secured with a password at the time of set up and that I am responsible for any illegal activity that is traced back to my IP address.

Typed Name *

Date *

Signature * 🛈

clear

My preferred email address *

Username * 🛈

Password * 🛈

Optional Features (for phone service)

Phone Features/Monthly Recurring Charges

IF YOU ARE ON PUBLIC ASSISTANCE PLEASE INQUIRE ABOUT LIFELINE

Directory Listing - Complete this section if you'll be using our phone service.

Published in Directory - no charge

Additional Directory Listing - $2.50/month

Unlisted (Not in directory but available through directory assistance - $1.50/month

Unpublished (Not in directory or directory assistance) - $2.00/month

Published in Directory as:

Additional Directory Listing, if any:

Plains Long Distance is available at .11 cents per minute, any time to any number in the 48 contiguous states, with no additional charges.

Yes, I'd like to add Plains Long Distance.

Customer Proprietary Network Information Notice of Changes

The FCC has implemented new rules that further strengthen the protection of your Customer Proprietary Network Information (CPNI). This effort by the Commission is in response to the practice of “pretexting” and provides additional privacy safeguards that will limit pretexters’ ability to obtain unauthorized access to your CPNI. “Pretexting” is the practice of pretending to be a particular customer or other authorized person in order to obtain access to that customer’s call detail or other private communication records. Several changes will be implemented that will affect the way Plains Communication Services and Plains Cooperative Telephone Association, Inc. (Plains) will conduct business with you in the future. Specifically, we are required to implement passwords for any customer initiated calls requesting call detail, be able to authenticate who you are as well as any additional authorized contacts you add to your account, and we are to notify you, as well as law enforcement should there be any unauthorized changes to your password, address, or account information. The new rules require that you provide a password before Plains can release certain information about your account. To establish a password, please fill out the information below, or contact a customer service representative at 970-592-2211 or 970-358-4211. Plains, in compliance with the FCC rules, will utilize new authentication methods to ensure that we are dealing with the authorized contact. Capital credits checks and allocations are written or sent to the person(s) whose name(s) is on the membership. Please be aware that simply by adding a person(s) name to your account does not entitle that person to any membership privileges or allow the contact any portion of capital credit funds. To add a name(s) to your current membership you will need to contact our office personally and indicate the person(s) name you wish to add. In order for Plains Telephone to discuss any details about your account with another party, such as your spouse, sibling, or other, they must be authorized by you and added to your account. If you would like to add another authorized contact to your account, such as a spouse or child, please fill out the information below or contact a customer service representative at the telephone number listed above. These rule changes are meant to protect you and your valuable customer proprietary information and to safeguard your privacy.

Question for authentication: What city were you born in? *

Question for authentication: What is the name of your favorite pet? *

Would you like to add any additional authorized contacts to your account? *

Yes

No

Name of additional authorized contacts:

Restricted Information Password * 🛈

Inside Wire Maintenance $1.00	Help Line $1.50
Voice Mail $4.50	Call Forwarding $1.50
Voice Mail to Email $6.50	Call Forwarding Busy $1.00
Call Waiting $1.50	Remote Call Forwarding $0.50
Cancel Call Waiting $0.50	Distinctive Ringing $3.00
Caller I.D. $4.25	Prerecorded Message $10.50
Caller I.D./CW Identity $1.00	Additional Directory Listing
Speed Dialing (8 digit) $1.50	Unlisted Number $1.50
Speed Dialing (30 digit) $3.50	Unpublished Number $2.00
Three Way Calling $1.50	900 Blocking (within 60 days) N/C
Automatic Recall $2.00	Toll Restriction N/C
Automatic Call Back $2.00	Per Line Blocking N/C

$64.95
$56.95
$69.95
$89.95
$99.95
$119.95
$149.95
$349.95
$7.00