Change of Service Request Form
*designates a required field
Name (First & Last)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Action
*
Add new service
Move existing service ($10 charge)
Change existing service
Disconnect
Internet- Inside City of Casey
5M- $44.95
10M- $54.95
15M- $59.95
25M- $64.95
Internet- Outside City of Casey
25M- $64.95
50M- $74.95
100 M- $84.95
200 M- $104.95
TV Packages
Local Package- $39.95/Month
Basic Package- (Local Included) $74.95/ Month
Expanded Package- (Local & Basic Included) $89.95/Month
Movie Packages
Starz/Encore Package- $12.95
Cinemax Package- $14.95
Showtime Package- $12.95
HBO Package- $14.95
Miscellaneous TV
Regular Receiver- $4.95/Month
100 GB Cloud DVR Storage- $4.95/Month
300 GB Cloud DVR Storage- $9.95/Month
Number of Receivers (1 per TV)
Telephone
Phone Service- $32.99
Caller ID, Call Waiting, Call Forwarding- Free
Long Distance Plan
I (we) hearby authorize CASEY MUTUAL TELEPHONE COMPANY to make these changes to my (our) account.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: