DeWitt Mound Business Service Application

Today’s Date*

MonthDayYear
Service Request Date

MonthDayYear
Applicant’s Name*
Cell Phone #*
Do we have permission to text you?*

YesNo
Business Telephone Number
SSN # or EIN*
Date of Birth*

MonthDayYear
Applicant’s Employer*
Work Phone*
E911 Address*
Billing Address (If Different)*
Email Address*
Do you want to add a co-applicant?*

YesNo
Co-Applicant’s Name*
Co-Applicant’s Cell Phone #*
Co-Applicant’s SSN # or EIN*
Co-Applicant’s Email Address
Co-Applicant’s Date Of Birth*

MonthDayYear
Co-Applicant’s Employer*
Co-Applicant’s Work Phone*
Select Billing Preference*

EmailPaperBoth
Do you want a GMC Email Address?*

YesNo
Email Username
username@gmtel.net
Email Passcode
*Passcode Requirements: minimum 8 characters, 1 CAPITAL letter, 1 lower case letter, 1 number & 1 special character (!#$*{>).
What services are you interested in?*

InternetVideoTelephone
Internet Service
Packages*

50 Mbps / 50 Mbps - $85.00110 Mbps / 110 Mbps - $110.00250 Mbps / 250 Mbps - $150.00500 Mbps / 500 Mbps - $200.001 Gig / 500 Mbps - $250.00
Internet Router Options*

Leased Router with WiFi Support - $9.95GMC install Customer Router - $25.00 (one-time charge)Customer will install own router
Preferred Wi-Fi Network Name*
Preferred Wi-Fi Passcode*
*Passcode Requirements: minimum 8 characters, 1 CAPITAL letter, 1 lower case letter, 1 number & 1 special character (!#$*{>).
Do you want to add an extender for larger spaces?*

Yes - $4.95No
How many static IP addresses?
($5.00 set up fee)
Static IP Address (up to 2) - $5.00

/29 Subnet (3-5 IP Addresses) - $10.00

/28 Subnet (5-13 IP Addresses) - $15.00
Video Service
Packages*

Light Package - $59.95I'm not interested in digital video service.
Do you want to use a Streaming Device or a Traditional Cable TV Set Up?

Streaming DeviceTraditional Cable TV
Customer Supplied Streaming Device (Firestick/Roku)

Customer InstallGMC Install Firestick/Roku - $50
How many Standard Set Top Boxes - $8.95
DVR Options with Increased Simultaneous Stream Available

250 GB: 5 Streams - $10.00500 GB: 10 Streams - $15.001 TB: 10 Streams - $20.00
Telephone Service
Packages*

Dial tone and Local Number Portability Options: Call Waiting, Call Forwarding & 3-Way Calling Extended Area Service (Includes Calamus, Charlotte, Delmar,, DeWitt, Low Moor and Welton - $30.00I'm not interested in phone service.
(Pricing on all of the above does not include taxes, fees or surcharges.)
RESTRICTIONS

If you choose to unblock any of these services, you will be responsible for any charges that may appear on your bill. (There is no monthly fee for these restriction services.)
900/976 Number BlockingInternational Call BlockingCollect Call BlockingThird Number Billing Block
APPLICANT’S SIGNATURE

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CO-APPLICANT’S SIGNATURE

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Directory Listing

Listed NumberUnlisted/Nonpublished Number ($.50/month)
Directory Listing
Do you want any additional listings?

Yes - $.50/monthNo
Directory Listing Name
Long Distance Plans

GMT LD 5A PlanGMT LD 5B PlanGMT LD State Flat Rate PlansGMT LD National Flat Rate PlansI do not want to add long distance to my phone plan.
Custom Calling Features

Call Waiting/Cancel Call Waiting - FreeForwarding Basic - Free3-Way Calling - FreeTelemarketing Do Not Disturb - FreeSingle Party Revertive - FreeToll Restriction w/PIN Override - FreeCaller ID Blocking - FreeCaller ID Number - $3.00Caller ID w/Name & Number - $3.50Caller ID/Call Waiting - $1.50Speed Calling 8 - $1.75Speed Calling 30 - $3.50Automatic Call Back - $1.00Automatic Recall - $1.00Automatic Call Back & Recall - $1.50Selective Call Acceptance - $1.00Selective Call Forward - $1.00Selective Call Rejection - $1.00Selective Distinctive Ring/Call Waiting - $1.00Anonymous Call Rejection - $1.00Call Forwarding Busy - $1.75Call Forwarding Don’t Answer - $1.75Voice Mail – Master Plan 30 - $5.95Night Service - $7.00
Grand Mound Cooperative Telephone offers many calling features that can be added to your telephone service. We are able to offer our customers the most up-to-date calling feature options. Check out the list below to see which options you would like to add. (There is a one-time charge of $20.00 to add a calling feature at a later date.)

Call Waiting/Cancel Call Waiting (FREE)

This option allows you to hear a tone on your line while you are talking on the phone, signaling that there is another incoming call. Cancel Call Waiting option (*70 to Activate) works with call waiting and allows you to cancel call waiting before you make a call. Once the call is ended, call waiting is automatically activated again.

Call Forwarding (FREE)

This is a user programmable option that allows you to forward all incoming calls to another directory number. When you are done call forwarding, simply go in and deactivate the call forwarding option. (*72 to Activate) (*73 to Deactivate)

3-way Calling (FREE)

This feature allows you to talk to two different people at the same time, and you can put one or both on hold.

900/976 Blocking (FREE)

This line option does not allow you to dial 900 or 976 numbers from your phone.

International Call Blocking (FREE)

This option does not allow you to make international telephone calls.

Caller ID Blocking (FREE)

This option allows you to block your name and number from being delivered to someone else's caller id. This option is on a per call basis. (*67 to Block) (*82 to Unblock)

Caller ID Name & Number Delivery (FREE)

With this option the subscriber will be able to see who is calling, as the name & number will be displayed on a caller id unit or phone.

Caller ID Number Delivery (FREE)

This option allows the subscriber to see the number of the person calling on the caller id unit or phone.

Call Waiting ID ($1.50/mo.) (Must also subscribe to Caller ID for this option.)

Allows you to see who is calling in while you are on the phone with someone else. You can then decide whether to answer the call waiting or not. Requires a caller id unit or phone that is capable of offering call wait ID.

Automatic Recall ($1.00/mo.)

With this feature you can dial a special code and your phone will automatically dial the last person who called you. (*69 to Activate)

Automatic Call Back ($1.00/mo.)

This option allows you to dial a special code and the last number you dialed will be redialed for you. (*66 to Activate)

Selective Call Acceptance ($1.00/mo.)

Want to accept only calls from a certain number or numbers? This option allows you to do just that. Program in the numbers and only calls from these numbers will go through.

(*64 to Activate) (*84 to Deactivate)

Selective Call Forwarding ($1.00/mo.)

Allows you to select which calls you want forwarded to another number. Just add the numbers to the list and only these calls will be forwarded. (*63 to Activate) (*83 to Deactivate)

Selective Call Rejection ($1.00/mo.)

Select the calls you do not want to receive. Any number you program in will be rejected and will not ring your phone. (*60 to Activate) (*80 to Deactivate)

Selective Distinctive Ring/CW ($1.00/mo.)

Want to tell who is calling by the ring? This option allows you to program in numbers and when they call, you will get two short rings instead of one long. (*61 to Activate) (*81 to Deactivate)

Anonymous Call Rejection ($1.00/mo.)

Reject phone calls that deliver their name & number as private.

(*77 to Activate) (*87 to Deactivate)

Call Forward Busy ($1.75/mo.)

This option allows your calls to be forwarded to another number if your line is busy. Great for when you are on the internet and don't want to miss a call. (*68 to Activate) (*88 to Deactivate)

Call Forward Don't Answer ($1.75/mo.)

This option allows you to forward all calls when you don't answer the phone. You can program how many rings before it forwards to another line. (*92 to Activate) (*93 to Deactivate)

Teen Line ($4.50/mo.)

This feature allows you to have a separate number that when called, it will ring differently than your main line. Know whether they are calling for you or someone else in the house. This option works over your main line and it will be busy if the teen line number is called and vice versa.

Telemarketing Do Not Disturb (Free)

If you have this option, anyone who calls you will have to press 1 in order for the call to ring into you. Computers that telemarketers use don't have that capability, therefore they can't get through.

(*78 to Activate) (*79 to Deactivate)

Toll Restriction w/ Pin Override (Free)

Dial a pin to make a long distance call. Without the pin, no toll calls can be placed from your phone.

Single Party Revertive (Free)

Call another extension in your house or garage and the phone will ring differently than normal. When it stops ringing, you know someone on another phone has picked up.
Important Notice

Many telephone customers have had their telephone service provider changed without their consent. This practice is known as “slamming”. In order to better serve you and keep you from getting your service changed without your authorization, we now provide a free service for our customers who would like to have more control over their telephone service. This free service is called a preferred carrier freeze. A preferred carrier freeze prevents a change in a subscriber’s service without the consent of the subscriber. The preferred carrier freeze can be placed on your intraLATA (Eastern Iowa region) and/or interLATA (National & International) telecommunications carriers. If you wish to place a preferred carrier freeze (PIC freeze) on your telephone service, please fill out the form below and return to the Grand Mound Communications office.

Once the preferred carrier freeze is in place, the freeze can only be lifted by you either through written or oral authorization. The authorization required for the lifting of the preferred carrier freeze is in addition to the regular verification process required to change to a different long distance service. The written authorization must be signed and state your intent to lift a preferred carrier freeze. It should also include your billing name and address and each telephone number to be affected. If you have a freeze on more than one service (intraLATA, interLATA), please also state which of the services are to be affected. The oral authorization can be initiated by the customer or can be a three-way conference call with you, the carrier to which you wish to switch, and one of our service representatives.
Request for Preferred Carrier Freeze (PIC Freeze)
Subscriber’s Billing Name
Address
Telephone Number(s) To Be Covered By Freeze
Please enter a valid phone number.
I would like to place a preferred carrier freeze on the following services and telephone number(s): Please mark the service that you would like to have frozen with respect to each one of your telephone number(s).
Plan to cancel

Long Distance – IntraLATA (Eastern Iowa Region)Long Distance – InterLATA (National & International)
Signature*

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Print Name*
Date*

MonthDayYear
Adding Authorized Users to Account

Under the new FCC rules governing the use and disclosure of Customer Proprietary Network Information (CPNI), Grand Mound Communications will only be allowed to discuss CPNI at our retail location with those listed as an authorized user on the account and carrying a photo ID. 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 call detail information and certain account information, including the amount of your bill. For telephone inquiries, other rules dictate how we authenticate a customer. In order to make your experience with Grand Mound Communications the best possible, we want to give you the option of adding authorized users to your account. Adding an authorized user does not mean that their name(s) will show up on the bill, but only that these persons will be allowed to discuss CPNI with our company representatives. Please take this opportunity to complete the section below and mail it back to us in the provided envelope.
Do you want to add an authorized user to your account?*

YesNo
Legal Name*
Do you want to add another authorized user to your account?*

YesNo
Legal Name
Do you want to add another authorized user to your account?

YesNo
Legal Name
Do you want to add another authorized user to your account?

YesNo
Legal Name
IMPORTANT: By signing below, the customer is expressly requesting that the company share certain account and call detail information, including Customer Proprietary Network Information, 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.
Account Owner/Business Name*
Print Name*
Account Owner/Business Name*

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Date*

MonthDayYear
Telephone Number(s) on Account*
Establishing an E-mail Address of Record

Under the new FCC rules governing the use and disclosure of Customer Proprietary Network Information (CPNI), there are certain circumstances under which Grand Mound Communications may be permitted to respond to your inquiries regarding call detail information or certain account information only by calling the telephone number listed on the account or sending such information to the mailing address or electronic address of record. Your mailing address of record is the billing address for your account. If you wish to establish an electronic address of record, you must notify us of the e-mail address you wish to designate as your electronic address of record. In order to be considered an electronic address of record, the designated e-mail address must be on file with the company for at least thirty (30) days. This form will establish an e-mail address as an electronic "address of record" only for purposes of service and account inquiries, including inquiries relating to CPNI. This form will not change the billing address for your account. If you wish to establish an electronic address of record for service and account inquiries, please take this opportunity to complete the section below and mail it back to us in the provided envelope.
Designated E-mail Address for Account Inquiries:*
IMPORTANT: By signing below, the customer is providing the company with express, written approval to communicate via the designated e-mail address in connection with service and account inquiries made by the account owner or designated account users. This approval includes responses to inquiries related to the customer's services generally and specifically to inquiries concerning call detail information and account information, including Customer Proprietary Network Information.
Account Owner
Telephone Number on Account
Account Owner

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Date

MonthDayYear
OPT-OUT Agreement

Grand Mound Communications and its affiliates want to use your CPNI to more effectively market communications-related products and services that you do not currently subscribe to—unless you tell the company not to do so. By completing the section below, you will be "opting out" of this agreement and denying use of your CPNI. If you do not respond within 33 days of our mailing date, it will be understood that you have given us approval to use your CPNI. You need only respond if you DO NOT want Grand Mound Communications and its affiliates to use your CPNI. If you choose to respond, please mail the completed section below back to Grand Mound Communications in the self-addressed, stamped envelope.
I DO NOT wish Grand Mound Communications or its affiliates to use my CPNI to market communications-related products and services that I do not presently subscribe to.*

YesNo
Account Owner*
Telephone Number on Account*
Account Owner*

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Date*

MonthDayYear
GMC TERMS AND CONDITIONS
1. By signing this registration form, you (user/customer) agree to the following terms and conditions of the service described on this page.

2. These services are provided by Grand Mound Communications (GMC), 705 Clinton St., Grand Mound, IA.

3. Telephone technical support is available upon activation of your account.

4. If your GMTel.net account is discontinued for any reason, GMC assumes no responsibility for recovery of your data.

5. GMC makes no express or implied warranty of any kind. There is no express or implied warranty of merchantability or fitness for a particular purpose for the services to be provided by GMC. GMC makes no attempt to verify accurate receipt of any message and is not responsible for any loss of data resulting from delays, nondeliveries, incorrect deliveries or service interruptions, including those caused by the negligence, errors, or omissions of GMTel.net, nor for consequential damages regardless of their cause.

6. Customer agrees to comply with the terms governing use of the GMTel.net network, as set forth in GMTel.net’s “Acceptable Use Policy”, as they may change from time to time. Any changes to the terms governing use of the GMTel.net network will be posted as warranted on the GMTel.net website.

7. This agreement shall be governed by and construed in accordance with the laws of the state of Iowa applicable to contracts to be performed entirely within the state.

8. By accessing and using the GMTel.net network, user is consenting to system monitoring for law enforcement and other purposes. Unauthorized use of, or access to, this computer system may subject users to criminal prosecution and penalties. User agrees to indemnify GMC against liability for any and all use of user’s account.

9. Internet connections may not be resold or otherwise provided to third parties that are not a part of this Agreement.
SPECIAL NOTES
- All connection speeds listed are maximum. Users may experience connection speeds less than noted.
- GMC connections are not to be used to host Web, FTP, DNS, SMTP, POP3 or other email servers.
- Certain restrictions may apply due to distance limitations.
- Additional installation fees may apply for work outside of a standard installation.
PLEASE READ THE FOLLOWING IMPORTANT INFORMATION BEFORE SIGNING:
          In making this application, we/I agree to the rules and regulations of Grand Mound Communications as set forth in the Exchange Tariff filed with the Iowa Utilities Board and Federal Communications Commission, as amended or changed from time to time.

          We/l agree to become a member of Grand Mound Communications if signing up for telephone, video or Internet services. Our/my membership in Grand Mound Communications is subject to paying our/my telephone, video or Internet services bills. Ownership of the membership in Grand Mound Communications will be issued by Grand Mound Communications to the applicant and co-applicant, if the co-applicant's name is listed above. Transfer of membership is governed by Grand Mound Communications' rules, but upon the death of the owner or co-owner, membership will automatically be transferred to the survivor thereof and subject to a deduction for unpaid services.

          We/l agree to these terms and conditions and rules of Grand Mound Communications, and each of us agrees to pay in full all telephone, video or Internet services bills upon receipt each month in which it is billed. If only the applicant or co-applicant signs below, I represent to you that I am the agent for the other applicant with authority to so act.
Applicant's Printed Name and Business Title*
Date*

MonthDayYear
Applicant's Signature*

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Co-Applicant's Printed Name and Business Title*
Date*

MonthDayYear
Co-Applicant's Signature*

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Please verify that you are human*
Should be Empty:

Internet Service

Video Service

Telephone Service

Important Notice

Request for Preferred Carrier Freeze (PIC Freeze)

Adding Authorized Users to Account

Establishing an E-mail Address of Record

OPT-OUT Agreement

GMC TERMS AND CONDITIONS

SPECIAL NOTES

PLEASE READ THE FOLLOWING IMPORTANT INFORMATION BEFORE SIGNING: