Alexandria Forada Grant Application

Account Information

Name of Applicant: *

First Name Last Name

Business Name: (if applicable)

If a business, please select one of the following:

Individual/Sole Proprietor Corporation Partnership Other

Preferred Connect Date:

Services will be connected as close to this date as possible

Service Address: *

Street Address

Street Address Line 2

City State

Zip Code

Billing Address (if different):

Street Address

Street Address Line 2

City State

Zip Code

Daytime Phone Number: *

Area Code Phone Number

Additional Contact Number:

Area Code Phone Number

Current Email:

example@example.com

I rent my home or apartment *

Yes No

Written permission from owner must be received in our office before wiring or outlets are done. if necessary.

Account Access Password: *

Account Access Password is required. This will keep your account secure and not allow anyone who is not authorized to request or receive information about your account.

Additional Authorized Contact(s):

High Speed Internet Service

Services Subject to Availability ~ Prices Subject to Change

Choose Your Internet Speed:

10-15 Mbps $76.95 20-30 Mbps $81.95 40-50 Mbps $89.95 75-100 Mbps $120.95 250-300 Mbps $145.95 500-1000 Mbps $169.95

I would like to lease a Managed Wi-Fi Router for $3.95 a month (a router is needed to make your internet service wireless)

Yes No

Desired username for runestone.net email address:

A runestone.net email address is optional. Customers are allowed up to 5 email addresses.

Desired Passcode:

Must be 16-80 characters, including one from each of these groups: (a-z) (A-Z) (0-9) (~@#$*( ) = -)

Prices subject to change • Must have Internet to have Telephone Service.

*Telephone Service includes unlimited Long Distance to the lower 48 United States. Some features included are Caller ID, Voice Mail and Call Waiting. Additional Charges apply for operator and directory assistance.

Type of Phone Service *Must read and agree to terms & conditions

Residential Line-- $29.95* Business Line-- $39.95*

*Receive a $10 telephone discount for subscribing to Runestone Internet Service

Signature

Clear

International Calling (Optional)

Check here to allow International Calling International rates apply. Must read and agree to terms and conditions.

Signature

Clear

Landline Phone Number to be ported (optional)

I have a current Landline phone number I would like ported

Directory Listing

Unpublished Listing - $1.00 (not published anywhere) Unlisted Listing - $0 (not in directory but in directory assistance) Directory Listing

Runestone Cable TV Service

Link to Packages and Channels

Choose the package that you would like:

Broadcast - $31.15 Basic - $76.63

Outlets Needed: (billed on time and material used)

Installation charge includes one free outlet

*Customers must also subscribe to Runestone Internet to have Cable Service. Not available to wireless customers.

Runestone Telecom Payment & Billing Options

Receive a $3.00 Bill Credit for by enrolling in all three:

eBill ~ Paperless Billing ~ Recurring Bank AutoPay

Ebill Authorization:

Sign Me Up For eBill: Enables you to view your bill and pay online

eBill User Name: (Must be your email address)

example@example.com

eBill Temporary Passcode:

You will be required to change your password the first time you log in

Paperless Billing:

Sign Me Up For Paperless Billing

You will receive your bill online only. Must be enrolled in eBill.

Recurring Bank AutoPay:

Sign Me Up For Recurring Bank AutoPay

Type of Account:

Checking Savings

Name of Financial Institution:

Routing Number:

Account Number:

Recurring Credit/Debit Card AutoPay: (Visa or MasterCard)

Sign Me Up For Recurring Credit or Debit Card AutoPay

Type of Card:

Visa MasterCard

Please call with card information

I would like my account to be paid automatically on the 20th of each month from my checking/savings account or credit/debit card for the amount due. This authorization will remain in effect until I notify Runestone Telecom in writing to cancel it. I can stop payment of a transaction by notifying Runestone Telecom 3 days before my account is charged.

AutoPay Authorization Signature:

Runestone Telecom Association Membership Agreement

Signature: By signing this you agree to comply with Runestone's Acricles of Incorporation, By-Laws, Rules and Regulations. *

Type Name *

Today's Date: *

Runestone Telecom Service Application

Runestone Telephone Service