IMPORTANT INFO: Call Completion Issues

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New Customer Application/Contract
Type(s) of Service:	Phone Video High-Speed High-Speed Wireless Dial-Up
Residential Customer Information (required info)
Responsible Party: *
Birth Date (mm-dd-yyyy): *
Password: *
Second name:	(Joint Account)
Birth Date (mm-dd-yyyy):
Password:
Mailing Address:
Physical Address: *
City: *
State: *
	Rent , Own
Can be Reached #: *
Customer Employment
Employer's Name:
Employer's Address:
Employer's City:
Employer's State:
Employer's Zip Code:
Supervisor's Name & Phone:
Nearest Relative Not Living With You
Name:
Address:
City:
State:
Phone:
Additional Information
Previous Service with VTG?	Yes, No
Previous Telephone #:
Port Number to VTG:	Yes, No
Number to be Ported:
Additional Features
DVR	Call Waiting
Internet Speed Upgrade	Caller ID
High Definition	Voicemail
Customer Term Agreement *
1 year agreement	(Installation fee may be required)
2 year agreement	(Free installation)
3 year agreement	(High Speed Wireless only)
Valley TeleCom Group Summary of Residential Services Subscriber Agreement The following is a summary of the Residential Services Subscriber Agreement (the “Agreement”) for services provided to you by affiliates of Valley TeleCom Group “VTG”. The full text of the Agreement and the associated Acceptable Use Policy are posted at the Valley TeleCom Group website, www.vtc.net. You may also obtain copies by calling any VTG office. The full version will control in all cases. Telephone service is offered under specific company tariffs as approved by state regulatory agencies. There are a number of “Services” (as set forth on this order form) to be provided by VTG which can include video, high-speed data and voice services. Your obligations and those of VTG are set forth in the Agreement, the Work Order for the placement of any equipment you order, any applicable provisions of the Acceptable Use Policy and, as appropriate, a “Tariff” describing charges that you may be required to pay VTG in those cases where rates are regulated by the Arizona Corporation Commission. VTG will notify you of any significant changes in any of these controlling documents (i.e. via a bill insert or bill message). Payment obligations. By signing the Agreement you agree to pay VTG on or before the due date for any use of Services, the installation charges, charges for damage to any equipment provided by VTG (if not returned in good condition) and all applicable federal, state and local taxes. You will be billed in advance for monthly recurring charges and other charges will be billed in the next feasible monthly billing cycle following use. You may also be charged late fees and early termination charges. Credit card billing is also available. Installation and maintenance. By signing the application for Services, the Agreement specifies that you will agree to allow VTG access to your house, apartment or other premises (including access easements) for both installation and maintenance of equipment during business hours and upon reasonable notice to you. If you are not the owner of the premises, by signing the Agreement you are warranting that you have obtained the consent of the owner of the premises for this access. If equipment is damaged, lost or stolen, the Agreement specifies that you will pay the replacement cost of the equipment as well as returning all equipment within ten working days of replacement or cancellation, including damaged equipment, to VTG. Use of Services. The Agreement specifies a number of limitations on the use of services. These limitations, among others, include a prohibition against reselling or retransmitting, the use of local phone service for telemarketing, call center, medical transcription or facsimile broadcasting, the use of high-speed data service for the operation as an Internet Service Provider or any form of transmitter or wide area network that enables anyone outside of your residence to use Services. Support and Repair. The Services provided include VTG’s obligation to provide reasonable service and maintenance of VTG owned equipment upon your request. VTG will repair or replace its equipment that has malfunctioned. You will be responsible for all wiring and other equipment that is not furnished by VTG, unless you obtained a service protection plan. Charges for VTG’s services that are not related to equipment malfunction or covered by a service protection plan are set forth in VTG’s price list posted at its website. Enforcement and Termination. If you violate the Agreement, VTG has the right to suspend or terminate all or a portion of Services without notification. If services are suspended or terminated, you will not be charged for services after the action, and will be refunded any pre-paid fees less any amounts due to VTG. Either VTG or you can terminate all or any portion of services at any time for any reason by giving notice by mail or by phone as specified in the subscriber notification to set up an appointment to remove equipment. You cannot terminate Services by writing “canceled” or similar message on a bill or check. Early termination may result in penalties. Installation charges with a one year agreement are $250 for Cable Television and/or High-Speed Internet. Reconnection fees for High-Speed Wireless, Cable TV and Telephone services are $25 for each service. Reconnect fee for High-Speed Internet is $95. Term of Agreement. The minimum term of agreement is selected on the New Customer Application Form. The term may be a component of the price plan you select. Early termination of services other than stand alone phone service, may result in penalties. Termination fees are as follows: $250 with one service (Cable TV or High-Speed Internet), $300 with two services (High-Speed Internet and Cable), and $300 with High-Speed Wireless. Terms of agreement are subject to change without notice. (See Residential Subscriber Agreement for full text.) If you fail to return any Valley TeleCom Group equipment you will be charged for any and all equipment costs. Prices are subject to change without notice. Other provisions. The full Agreement contains disclaimers of warranty and limitations of liability, describes your privacy rights, and, unless you specifically request otherwise, consents to VTG calling you to market its current and future Services. You also have agreed that, unless specified otherwise, all notices may be made by electronic means (for example, email or online posting). Statement of Nondiscrimination. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, religion, age disability (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.
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