Application for Service

Date

1st Contact Full Name*

(Monthly bill will be in this person(s) name – list jointly if so desired)

Do you want to add a second contact?

YesNo

2nd Contact Full Name

Service Address*

City*

State*

Billing Address (If different)

Cell Number*

Date of Birth*

Employer*

Employer's Phone Number

Preferred Email Address*

Cell Number

Date of Birth

Employer

Employer's Phone Number

Preferred Email Address

Under the new FCC rules governing the use and disclosure of Customer Proprietary Network Information (CPNI), Colo Telephone Company and Central Iowa Brodband will only be allowed to discuss CPNI at our office with those listed as an authorized user on the account. The only exceptions may be for certain routine customer service issues if you have all pertinent information with you, such as the bill or call detail information you wish to discuss. Remember, CPNI includes all detail information and certain account information, including the amount of your bill. For telephone inquiries, other rules dictate how we authenticate a customer. By signing below, the customer is expressly requesting that the company share certain account and call detail information, including CPNI, with authorized account users and is authorizing the company to share such information with authorized users as necessary to address service and account inquiries initiated by the account owner or any authorized user.

Owner Passphrase*

(To verify account owner for changes made over phone)

Authorized User*

City born*

Applicant Signature*

Do you want to add additional authorized users?*

YesNo

Additional Authorized Users

City born

Applicant Signature

What services are you interested in?*

InternetPhone

PHONE SERVICE

Phone ($22.50/month - Colo Telephone -- $20.00/month - CIB)

Directory listing

One free listing with service. Indicate how you would like to be listed in the directory.

Additional Directory listing

$1.50 per year

I want my number non-pubished ($3.00/month)

INTERNET SERVICE

Starter - $80.00/monthPremium - $100.00/monthElite - $155.00/month

Access Code used when calling INS Tech Support

(to verify account owner for after hours support)

Passphrase Code

(PassPhrase must be between 8-20 characters, with one uppercase, one lowercase and one digit, cannot be the same as username)

Username - @netins.net

Managed Wi-Fi Services

ExperienceIQ ($8.00/month)Giga-Mesh extender ($6.50/month)

I understand that HIGH SPEED DATA is a ‘constant connection’ to the Internet and is more susceptible to security breaches. I will not hold Colo Telephone and CIB liable for any system problems including loss of data or security related problems. I also understand that this service is strictly for subscriber use.

If a letter of credit is received the deposit for services can be waived.

APPLICANT INITIAL*

*I understand that except for the applicant’s spouse, only the applicant (person(s) signing this application) is responsible for the bill generated from Colo Telephone Company and Central Iowa Broadband *The applicant(s) agrees to pay established rates for all such services and equipment. In submitting this application, the signatory agrees to abide by the rules and regulations of Colo Telephone Company and Central Iowa Broadband for the service furnished under this application. I understand submission of this application to Colo Telephone Company and Central Iowa Broadband constitutes an offer, and when accepted in writing by Colo Telephone Company and Central Iowa Broadband, becomes a binding contract for broadband service for the term defined in this document. * I understand that when an appointment is scheduled for the installation of my services, I am responsible for ensuring that someone 18 years or older is present at my home for the duration of the installation. Employees of Colo Telephone Company and Central Iowa Broadband will not enter my home to complete installation of services if someone over the age of 18 is not present at the scheduled appointment time. *I understand that Colo Telephone Company and Central Iowa Broadband reserves the right to assess a trip charge in the amount of $30.00 if the customer is not present at the agreed upon installation appointment time. *I understand monthly service for local telephone, internet and DTV services are billed one month in advance and long-distance charges are billed in arrears and any usage charges for long distance are billed in arrears. *I understand my first bill will include any prorated amount for service from the installation date through end of the current billing cycle. *I understand the bill is due upon receipt. If the bill is not paid by the end of the day on the 20 of each month, it is late and will incur a late fee on the balance. Late fees apply even if a payment arrangement has been approved. If a bill is not paid and no arrangements have been approved by the 26of the month, services will be disconnected until payment is received at Colo Telephone Company and Central Iowa Broadband in full. Once payment has been received, services will be reconnected and a reconnect fee of $30.00 per disconnected service will be applied. *All equipment installed or provided to you remains property of Colo Telephone Company and Central Iowa Broadband and must be returned to our business office upon disconnection of services. Failure to return equipment will result in your account being billed for the full retail price of the equipment. *FTTH Customers – The applicant agrees to provide a 110 outlet for power within 15 feet of the UDP (box located outside your house) and assume responsibility for the cost of the electricity.

For further Terms and Conditions of Service: colotel.org or centraliowabroadband.org

First Contact Information

Second Contact Information

PLEASE READ CAREFULLY TERMS AND CONDITIONS OF SERVICE: