Service Sign-Up Form

General Information
What type of service are you looking for?*

ResidentialBusiness
First Name*
Last Name*
Date of Birth

MonthDayYear
Business Name*
Service (Street) Address*
City*
Township*
State*

Street Address

Street Address Line 2

City

Postal / Zip Code
Zip Code*

Street Address

Street Address Line 2

CityState
Is your billing address different than your street address?*

YesNo
Billing Address (Street or P.O. Box)*
Billing City*
Billing State*

Street Address

Street Address Line 2

City

Postal / Zip Code
Billing Zip Code*

Street Address

Street Address Line 2

CityState
Email Address*
Cell Phone Number*
Have you had service with NTEC/Nelson Tel/Chippewa Valley Cable?*

YesNo

Personal Information

Please answer the following questions. You will need to use this passphrase or know the answer to one back-up question when calling in to discuss your account or make any changes to your account.
Authorized User(s) to request info or make changes to your account*
Account Access Passphrase*
Backup Questions

Answer two of the following back-up questions.
What is your favorite holiday?
What is your favorite vacation location?
What is your mother’s maiden name?
What town were you born in?
Billing Information
How should we send your monthly bill?*

Paperless (via e-mail)Paper (via USPS) $5.00 Environmental charge per month
Would you like information on Automatic Payments?*

YesNo
I understand that this application is for my personal or business use only and is not to be resold to others. For information on our wholesale rates please contact our business office, we reserve the right to refuse service to anyone.*

I agree to not resell services.
The undersigned, hereinafter called the “Applicant”, hereby applies for telephone service with Nelson Communications Cooperative, a corporation duly organized and existing under and by virtue of the laws of the State of Wisconsin, hereinafter called the “Cooperative”, for the purpose of having furnished to said “Applicant” telephone services upon the following terms and conditions: The “Applicant” will take from the “Cooperative” telephone services when available and will pay monthly rentals to the “Cooperative” in accordance with the rate schedules and rules and regulations established by the “Cooperative” in accordance with the directives of the United States of America and the State of Wisconsin and their regulatory bodies. The “Applicant” hereby grants to the “Cooperative”, a right-of-way easement to construct, operate and maintain a telephone line or system on its or his premises and in or upon all streets, roads or highways abutting said premises, and also such service lines are necessary, and also the right to cut or trim trees and to bury cable necessary to the efficient operation of said system. The “applicant” will comply with and be bound by the provisions of the bylaws, rules and regulations of this Association and such amendments as may from time to time be adopted.

Important information regarding your privacy and records with Ntec & Affiliates

It is Ntec's responsibility under federal law to protect the confidentiality of your Customer Proprietary Network Information (CPNI). CPNI is any information that is not publicly available and includes the type of phone service you receive from Ntec, the number of lines, amount of usage and call detail.

As a customer, you have the right at any time to restrict the use of CPNI for marketing purposes. If you choose not to permit us to disclose your CPNI records that you have with Ntec and affiliates, you may opt-out, however, restricting CPNI may make you ineligible to receive information from Ntec and our affiliates about new products and services, packaged offerings and various promotions.

I do want to receive direct marketing materials from Ntec & affiliates. To opt-out, please contact the business office.
Select the box below to to agree to terms.*

Agree to Terms
Signature (Type in First, Middle Initial and Last)*

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