Service Application

Service Application
Personal information
Name*

First Name Last Name
Mailing Address*

Address Line 1

Address Line 2

City State / Province

Postal / Zip Code
Physical Location of Service Connect*
type NA if applying for cell phone.
Current Cell Phone Number*

Area Code Phone Number
Email*
example@example.com
How would you like to receive your bill?*

By MailBy Email onlyBy Mail and Email
May we use your Email to Contact you?*

YesNo

Date of Birth*

MonthDay Year
Date
Social Security Number*
Just the number with no dashes
Drivers License Number and State of Issuance*
Employer*
Length of Employment*
Occupation*
Employer Contact Number*

Area Code Phone Number
Close Relative Name*
Close Relative Relationship *
Close Relative Phone Number*

Area Code Phone Number
Close Relative Address*

Address

Address Line 2

City State / Province

Postal / Zip Code
Do you own or rent your home?*

OwnRent
If you rent your home, please list your Landlord's Name
Will there be a Co-Applicant, such as a spouse, listed on your account?*

YesNo

Co-Applicant Information
Co-Applicant Name

First Name Last Name
Co-Applicant Email
example@example.com
Co-Applicant Cell Phone

Area Code Phone Number
Co-Applicant Date of Birth

MonthDay Year
Date
Co-Applicant Driver's License Number and State of Issuance
Co-Applicant Social Security Number
Just the Numbers with no dashes
Co-Applicant Employer
Employer Phone Number

Area Code Phone Number
Co-Applicant Length of Employment
Occupation

Have you had previous telephone service with CTC?*

YesNo
If so, is there an outstanding balance on that account?*

YesNo
If a Service Call is required, I understand I will be billed at the hourly rate of $72.50/hour for time and materials.*
Please initial to agree
Do you or anyone in your household have any disabilities that may inhibit access to our service offerings?*

YesNo
If you answered yes to the question above, please explain.
Additional Information
Please provide any additional information we may need to know to complete your order, such as a description of your location, name of previous resident if known, or anything else that you wish to let us know.
I declare that the information provided is true, accurate and complete to the best of my knowledge, and is voluntarily submitted for the purpose of receiving telephone service in Cordova.
I hereby agree to pay all service charges, toll charges and monthly charges as set forth in the Cooperative's tariff. I understand that CTC mails the billing for this service between the first and the fifth of every month and that payment must be received in full by the 20th of each month. Failure to pay by this date will result in written notice of past due status and will subject my account to suspension if not paid in ten days. Service, if suspended, will not be restored until full payment plus a $25 reconnect charge is received.
Should I fail to make complete payment for services rendered after disconnection of my service, I understand that CTC will have the right to pursue collection against me. I agree to pay all reasonable costs incurred in the collection process as well as any applicable interest due as set forth in the Cooperative's tariff.
I understand that the deposits required are separate from my monthly billing and that CTC will hold any said deposits until such time as follows:
1. Instrument Deposit: Until instrument is returned.
2. Security Deposit: 60 days following termination of service or upon establishment of two (2) years of continuous good credit with no more than two (2) disconnect notices.
I hereby certify that I am at least eighteen (18) years of age and agree to abide by the bylaws of this Cooperative. I have read the above information and understand that this application for service becomes that property of the Cooperative and is not to be used for any other purpose than in connection with my account.
Signature
Please verify that you are human*

What type of Service are you looking for?*

Landline OnlyInternet OnlyLandline and Internet ServiceCell PhoneInternet Only and Cell PhoneLandline, Internet and Cell Phone Service
When would you like services to begin?

MonthDay Year
We will get as close to this date as possible. Please note that we are closed on weekends and most major holidays and cannot begin service on those date.

Member Only DSL Service

Please only complete if you wanted DSL service with your Landline
Please choose a DSL Package
Packages are based on speed. Please see table below for Maximum Usage and price per month.
A VDSL modem is required for all packages. We offer these modem/router combination units for rent or purchase.
Modem Options

I will purchase a VDSL modem for $159.00I will rent a VDSL modem/router combo for $5.60/month
By leasing a modem/router from CTC, I acknowledge I must return the equipment if I disconnect service and if I do not return the equipment within 5 days of disconnect I will be charged the full price of the unit.
Please type initials as agreement of lease policy.
Please choose a Network Name for your Wifi Network
Please choose a Password for your Wifi Network
Please choose a login name for your internet connection.
Please use all lowercase letters.
Please choose a password for your internet connection.
Must be at least 8 characters, 1 uppercase & 1 number
Please review our Internet Privacy and acceptable Use Policies at your earliest convenience. Sign below to acknowledge it is your obligation to read and follow these policies or your service may be terminated.
Signature
Would you like to continue to Cell Phone Service?

Yes Please.No Thank You.

Non-Member DSL Packages

These packages do not include membership to the cooperative.
Please choose a DSL Package
Packages are based on speed. Please see table below for Maximum Usage and price per month.
A VDSL modem is required for all packages. We offer these as modem/router combination units for rent or purchase.
Modem Options

I will purchase a VDSL modem for $159.00I will rent a VDSL modem/router combo for $5.60/month
By leasing a modem/router from CTC, I acknowledge I must return the equipment if I disconnect service and if I do not return the equipment within 5 days of disconnect I will be charged the full price of the unit.
Please type initials as agreement of lease policy.
Please choose a Network Name for your Wifi Network
Please choose a Password for your Wifi Network
Please choose a login name for your internet connection.
Please use all lowercase letters.
Please choose a password for your internet connection.
Must be at least 8 characters, 1 uppercase & 1 number
Please review our Internet Privacy and acceptable Use Policies at your earliest convenience. Sign below to acknowledge it is your obligation to read and follow these policies or your service may be terminated.
Signature
Would you like to continue to Cell Phone Service?

Yes Please.No Thank You.

CPNI Registration
In accordance with the Federal Communications Commission’s (FCC) Customer Propriety Network Information (CPNI) rules, communication companies are required to set up password protection for your account. CPNI is information that communication companies acquire about their subscribers. It includes not only what services are used but the amount and type of usage. CPNI does not include your name, address, or phone number.
Name on Account*

First Name Last Name
Cordova Telephone Cooperative and Cordova Wireless Communications are serious about keeping your information safe from pre-texting (someone calling us and pretending to be you). When a customer asks for information on their, account a PIN or Password must be confirmed before information about the account is released. The person’s name that appears on the bill is the ONLY person authorized to make inquiries on this account, either in person or by phone. If you want to allow someone else to make inquiries on this account, for example your spouse, simply print their name(s) below.
Name 1

First Name Last Name
Name 2

First Name Last Name
Account Password*
Secret Question (Pick One – The will allow CTC to release your password to you or others with the correct answer):
Choose a question*
Answer*
We are committed to respecting and protecting the privacy of our members. CTC and CWC do not sell or provide customer information to third parties for sales or marketing purposes. For more detailed information, please refer to our privacy policy.
Date*

MonthDay Year
Date
Signature
Should be Empty:

Service Application

Personal information

Co-Applicant Information

Landline Service

Member Only DSL Service

Non-Member DSL Packages

Cellular Service

CPNI Registration