Customer Service Agreement

CUSTOMER INFORMATION
Do you currently have Internet?*

YesNo
Who is your current provider?*
Service Type*

ResidentialBusiness
Name*
Address*
City*
State*
Zip Code*
Phone Number*
Work Phone Number
SSN*
Federal Tax ID Number
Requested Passcode*
Your Mother's Maiden Name*
Are you tax exempt?*

YesNo
What type of services would you like to purchase?*

Bundled ServicesIndividual Services
What type of services would you like to purchase?*

Bundled ServicesIndividual Services
Which individual services?

InternetTelephoneVideo
Which individual services?

InternetTelephoneVideo
Bundle Options*

Call + Click + Watch - Local phone service, Voicemail, Caller ID, Internet (up to 200 Mb), DynamicTV Premium, 250 minutes of Palmer long distance - $204.95/month*Call + Click - Local phone service, Voicemail, Caller ID, Internet (up to 200 Mb), 100 minutes of Palmer long distance - $70.95/month*Call - Local phone service, Voicemail, Caller ID and 100 minutes of Palmer long distance - $36.00/month*I'm not interested in bundling services.
Internet - Telephone Service Required*

200 Mbps - $44.95/month*400Mbps - $79.95/month*600Mbps - $149.95/month*1 Gig - Call for details.I'm not interested in internet with telephone service.
Internet Alone*

200 Mbps - $79.95/month*I'm not interested in an internet only plan.
Telephone - Residential*

Includes unlimited local calling - $20.00/month**I'm not interested in stand alone telephone service.
Long Distance Plans*

10 cents per minute plus a $3.95 monthly fee14 cents per minute with no monthly fee100 Minutes – $8.00/month250 Minutes – $20.00/month500 Minutes – $40.00/monthI'm not interested in long distance telephone service.
What calling features are you interested in?

Call WaitingCall ForwardingCaller IDSpeed CallingThree-Way CallingVoice Mail
TV

Basic - $59.00/monthBasic Plus - $124.00/monthPremium - $136.00/monthI'm not interested in TV service.
Additional $20 per month charge if the accountholder does not subscribe to Palmer Mutual Telephone Company’s internet.
Premium Channels

Cinemax - $10.00HBO - $17.50Showtime - $15.00Starz - $10.00
Do you want additional HD Boxes?*

YesNo
How many?
$5.00 each
Do you want additional HD DVR?*

YesNo
How many?
$10.00 each
Telephone - Business*

Includes unlimited local calling - $23.00/month***I'm not interested in telephone service.
*Plus $95 Installation on all plans (waived with 6 month service). Speeds dependent on network activity. There will be a no charge site survey to make sure your location is high-speed-ready.
**Subscriber line charge (single-line) – $6.50/month

***Subscriber line charge (multi-line business) – $9.20/month
STANDARD INSTALLATION TERMS
*Standard installation includes installation of fiber internet equipment and connection to one computer. Installations that require extraordinary time or resources will be billed an additional charge. Customer will be informed of charges prior to installation. Monthly service charge includes use of PMTC's fiber internet equipment. Ownership is retained by Palmer Mutual Telephone.
I agree to the terms of the Standard Installation - Please Initial*
Date*

MonthDayYear
CUSTOMER SERVICE AGREEMENT
I understand and acknowledge that continued use of PMTC's Services constitutes acceptance of the Terms of Service, Acceptable Use Policy, and other important policies posted on PMTC's website, www.palmerone.com. I agree it is my responsibility to read these policies and comply fully with their terms. I further understand the policies and pricing of Northwest's Services may change from time to time upon 30 days notice. The Service is provided on an "AS IS" and "AS AVAILABLE" BASIS WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO WARRANTIES OF TITLE OR IMPLIED WARRANTIES OF MERCHANTABILITY

OR FITNESS FOR A PARTICULAR PURPOSE. If service is cancelled, customer agrees to return the equipment in working order within 10 business days or pay an equipment charge of $200.
I agree to these terms - Please Initial*
Date*

MonthDayYear
To request a copy of our Terms of Service, Acceptable Use Policy, Open Internet Policy and other policies, call our Customer Care Department at 712-359-2411
CUSTOMER SIGNATURE
Signing this order form and agreement indicates I accept and understand the Customer Service Agreement and the Standard Installation Terms.
Signature*

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Date*

MonthDayYear
IMPORTANT CUSTOMER NOTICE
RE: NEW FCC requirements for Palmer Customers Account access Effective in December of 2007, the FCC has implemented new rules to protect the privacy of information contained in your telephone account with Palmer Mutual Telephone Company. The new rules allow us to discuss account information only with the person(s) listed on the account. Failure of Palmer Mutual Telephone Company to do this can result in substantial fines and penalties. Please review the second page for more details on the new rules. Also, we must be able to authenticate that person and will do that by one of the following ways according to the new FCC rules:

1. Ask for a previously set password.

2.Call you back at the Phone number on record.

3.Mail information to the Address on record.

4. View a photo ID.

Although we have always treated your account information with confidentiality, please help us in our effort to further ensure that we protect your information, by completing the following:
Requested Passcode
(At least 6 alphanumeric characters)
Authentication Question: What is your favorite color?
If your account is listed only in your name, you might want to consider adding another name, if appropriate, e.g., a spouse or a roommate. If you are a parent or individual that relies on someone else to discuss account changes, payments or anything else with Palmer Mutual Telephone Company, you will need to have that person's name added to your account. The name does not need to be added to the billing name or directory but can be added to our records as an authorized person for discussing information and making changes to your account. The additional contact(s) that you authorize will not be responsible for payment of this account.
I would like to add the following as authorized contacts for my account
Please Print Legal Name
Do you want to change your directory listing to add any of the above names?

YesNo
Which ones?
Account Telephone Number(s)
Signature of person currently listed on account

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PALMER MUTUAL TELEPHONE COMPANY EMAIL AGREEMENT
I, ___________________ wish to have my Monthly Statement emailed to the following email address.
Full Name
Email
Customer Phone/Acct #
Customer Signature

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CUSTOMER INFORMATION

STANDARD INSTALLATION TERMS

CUSTOMER SERVICE AGREEMENT

CUSTOMER SIGNATURE

IMPORTANT CUSTOMER NOTICE

PALMER MUTUAL TELEPHONE COMPANY EMAIL AGREEMENT