Yakutat Residential Service Application

Service Application
Personal information
Name*

First NameLast Name
Mailing Address*

Address Line 1

Address Line 2

CityState / Province

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

Area CodePhone 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*

MonthDayYear
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 CodePhone Number
Close Relative Name*
Close Relative Relationship *
Close Relative Phone Number*

Area CodePhone Number
Close Relative Address*

Address

Address Line 2

CityState / 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 NameLast Name
Co-Applicant Email
example@example.com
Co-Applicant Cell Phone

Area CodePhone Number
Co-Applicant Date of Birth

MonthDayYear
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 CodePhone Number
Co-Applicant Length of Employment
Occupation

Have you had previous service with YTC?*

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 internet service in Yakutat. I hereby agree to pay all service charges, toll charges and monthly charges as set forth by Yakutat Telecom Company. I understand that YTC 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 YTC 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 by Yakutat Telecom Company.

I understand that the deposits required are separate from my monthly billing and that YTC will hold any said deposits until such time as follows:

1. 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

When would you like services to begin?

MonthDayYear
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. PLEASE NOTE SERVICES IN YAKUTAT WILL NOT BE AVAILABLE UNTIL FALL OF 2024.

Internet Service

Please only complete for DSL Service
Please choose a DSL Package
Packages are based on speed. Please see table below for Maximum Usage and price per month.
A fiber Modem/Router will be provided by Yakutat Telecom Company through the NICEY grant. This equipment is the property of YTC and will not be removed from the premises except by authorized YTC personnel.
I understand that the equipment provided to me by YTC for internet access belongs to YTC and is not to be removed from the premises upon termination of service.
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 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

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 NameLast Name
Yakutat Telecom Company is 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 NameLast Name
Contact Number

Area CodePhone Number
Name 2

First NameLast Name
Contact Number

Area CodePhone Number
Account Password*
Secret Question (Pick One – This will allow YTC 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. YTC does 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*

MonthDayYear
Date
Signature
Should be Empty:

Service Application

Personal information

Co-Applicant Information

Internet Service

CPNI Registration