Application For Telephone Service

Application for Business Telephone/Internet Service Mt. Rushmore Telephone Company

Please complete the following and return with appropriate fees to our office: 320 First St, PO Box 669, Keystone, SD 57751 Phone: 605-666-4411 or 605-255-4771 FAX 605-666-4611

Customer Information

Name: _____________________________________________ Requested Date of Installation: ___________________ Contact number: (______) ____________________________ Cell Phone: (______) ___________________________ Text? Y/N Date of Birth: _________________________________ E-mail address: ____________________________________ Mailing address: _____________________________________ 911 Service Address: ___________________________________ City: ________________________________ State: _______ Zip Code: _________ County: _____________________________ Must have 911 address to hook-up phone service If a rural address, please provide directions:

Do you rent or own your home? _______, if renting, Landlord's Name: _____________________________________ Would you like information regarding the Automatic Payment Plan? Y/N

Phone & Internet__________ Phone Only_____________ Internet Only______________

Would you like long distance service? Y/N Which long distance company do you prefer? _________________________

Please be reminded, that you will need to contact the long distance company to set up a calling plan suitable to your needs. Would you like your number to be: Published or Unpublished? Would you like permanent line blocking? Y/N

Permanent line blocking prevents the display of your name and number at all times when you call someone who has caller identification. If you want to identify yourself for just one call, you will be required to press *82 before you dial the number. After you hang up, line blocking will resume. Please circle the features you would like: Call Waiting (an additional $5.00 per month)

Caller Identification (an additional $5.95 per month) Voicemail (an additional $6.95 per month) Inside Wire Maintenance (an additional charge per month & certain restrictions apply) Option to accept Collect Calls Option to accept Third party charges

Current Employer: ______________________________ Phone Number_______________________________ Address: _________________________________________________________________________________ How long have you worked for this company: ____________________________________________________ Social Security Number/EIN__________________________________________________________________ The information on this application is correct and is given for the purpose of obtaining credit. Fort Randall 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 Mt. Rushmore 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 Mt. Rushmore Telephone Company.

Applicant's Signature: ______________________________ Application Date: ____________________

Internet Modem is owned by Mt. Rushmore Telephone Company. You must return modem to Mt. Rushmore Telephone before we

will disconnect your service or you will be charged $100.00. Applicant's Initials: ______

Customer's Previous Telephone Number: Customer's Previous Address:

How long were you at the above address?

Customer Credit History

(______) ___________________________________ ___________________________________________ ___________________________________________ ___________________________________________

___________________________________________

Bank Name: Address:

Phone: Type of Account:

Credit References

_________________________________________________ _________________________________________________ _________________________________________________

_____________________________________________________

( ) _________________________________ Checking _____ Savings______

Trade References

(List companies where you have established credit for example: utility company, home, car, or college loan)

Company Name:

__________________________________________________

Address:

__________________________________________________

__________________________________________________

__________________________________________________

Phone:

( ) _________________________________

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