Bellevue Offer Wireless Application

Full Name*
Cell Phone Number*
Contact Email Addresses*
example@example.com
Would you like to add a secondary contact onto your account?

YesNo
Secondary Contact Full Name*
Cell Phone Number*
Contact Email Addresses*
example@example.com
A COPY OF YOUR PHOTO I.D. OR DRIVER'S LICENSE IS REQUIRED

Cancelof
E911 Service Address*
City*
State*
Zip Code*
Is your billing address the same as your service address?

YesNo
Billing Address*
City*
State*
Zip Code*
Do you rent or own?*

RentOwn
One-time $30 connection fee.
Property Owner Name*
Property Owner Phone Number*
Please enter a valid phone number.
$100 security deposit is required.
Bill Medium*

Email (via contact email address above)Paper
Internet Service
Internet Plans*

100/100 Mbps for $50/mth250/250 Mbps for $65/mth500/500 Mbps for $75/mth
Email Address
example@netins.net
Internet Security Service

Tech Home combines the best security, backup, data management and Wi-Fi assessment software-all with 24/7 support. Learn more at www.securitycoverage.com/solutions/tech-home/. Provided through NRTC Manged Services.
Tech Home Protect: $6.99/mth

Yes - INCLUDES: Web security for 1 PC & 1 mobile device, 50GB file backup, passcode management.No
Tech Home Protect Plus: $10.99/mth

Yes - INCLUDES: Web security for up to 4 PCs & mobile devices, 250GB file backup, passcode management.No
Tech Home Support: $15.99/mth

Yes - INCLUDES: Entire Protect Plus package shown above, plus 24/7/365 whole home premium technical support for all of your Internet-connected electronics (printers, SmartTVs, gaming systems, etc.)No
United States-based 24/7 Tech Line: 877-373-3320, then press 3 for Tech Home services
HomePass By Plume

Router Rental
Key Features of Plume Homepass App:
- 1st intelligent WI-FI service platform for smart home experience that provides control of home & Interent Services
- Real-time protection (antivirus, malware, etc)
- Built in Ad Blocking
- Easier parental controls (device freeze)
- View of all connected devices for easier management
- Multiple users (adults separate from kids/friends)
- If router is acting strange, self-quarantines
- Motion detection through devices already connected to your network
Do you want to add Plume Homepass and Router?*

Yes - $10/mthNo
Customer Proprietary Network Information

Keeping your nonpublic account information safe from unauthorized access is important to us. Under federal law, you have a right and La Motte & Andrew Telephone Company has a duty, to protect the confidentiality of your CPNI. Please designate a passcode that we'll use to confirm your identity before discussing private account details. If you forget your passcode, we'll ask you the back-up questions.
Passcode for Account Inquiries
If you forget your passcode, we can ask you backup security questions. Please answer ONE of the following two questions.
In what city were you born?
What high school did you attend?
Please answer ONE of the following two questions
What is the name of the street you grew up on?
What is the name of your favorite pet?
CPNI Authorization
May we let you know about new services or Internet speeds, if they become available, based on your current services? (We DO NOT telemarket or share your information with any entities outside the scope necessary to provide your services.) This is also known as CPNI authorization. If left blank, we will adopt a policy, as allowed by the FCC, to consider consent given.*

YesNo
*If you grant permission now, you have a right to tell us in writing later that you do not wish us to use your information for this purpose. However, be aware that this would generally mean that the free flow of information needed to reap the benefits of more personalized service or cost savings would be limited by the restriction to CPNI information. We may not be able to let you know about services that may interest you
Authorized Account Users

Below you may add authorized users to your account. Authorized users do not show up on the billing statements, but are those persons who can make billing inquiries, make changes on the account, and with whom we have your permission to discuss nonpublic account information as needed on your behalf
1st Authorized User's Full Name
1st Authorized User's Phone number
Do you want to add another authorized user?

YesNo
2nd Authorized User's Full Name
2nd Authorized User's Phone number
Do you want to add another authorized user?

YesNo
3rd Authorized User's Full Name
3rd Authorized User's Phone number
Terms and Conditions

By establishing an account with La Motte & Andrew Telephone Company, you agree to the Acknowledgement of Services & Policies, Customer Release, 24-month agreement, and to abide by all lawful use of subscribed services. The full details of these terms can be found on our Company website at www.lamotte-telco.com. Below is a summary of these terms and conditions.
Please read and INITIAL each item below:
I am the person I claim to be, and I am not opening this account in anyone else's name.*
It is my responsibility to keep my account updated with current names, addresses, payment information, and contact information.*
I am aware that there are monthly charges for the services I am requesting; that payment is due by the 20th of each month; and that services are subject to disconnection for nonpayment, resulting in a fee to reconnect services.*
By requesting services, I agree to allow Company technicians to enter my home at the appointed time and date for installation or service purposes.*
By requesting service to my premise, I grant an easement to the Company to plow or bore fiber or communications cable to my premise in order for the Company to provide requested services to my premise.*
I assume all risks associated with the services I am requesting, including any equipment required to provide these services; and release from any liability La Motte & Andrew Telephone Company, their respective officers, and employees.*
I understand that Company-owned equipment, at the time of permanent disconnection of services, must be returned to the Company in good condition-normal - wear and tear is expected.*
I agree to keep the requested services for a minimum of 24 months in lieu of a $100 installation charge. If I discontinue service within that 24-month period, the $100 fee is prorated (equal to approximately $4.17 per month not fulfilled)*
I won't rebroadcast / resell the Internet or TV signal / connection in any manner or use the services to break any state or federal laws.*
I understand that federal law mandates periodic testing of Internet speeds at customer premises, and if selected as a testing site, the Company has permission to do testing and to install necessary equipment to comply with the FCC mandatory testing requirement.*
I understand that if I don't comply with stated terms and policies, my service may be terminated by La Motte & Andrew Telephone Company without notice.*
I understand that La Motte & Andrew Telephone Company's policies and procedures may be updated periodically, and that those updates will be posted to the Company website at www.lamotte- telco.com.*
Customer Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Secondary Customer Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
AutoPay

Accounts are billed monthly for service. You will receive your bill for that month at the beginning of each month. Payment is due upon receipt, and is considered late after the 20th of each month. A late fee of $7.00 applies and a disconnect notice generates and mails on the 21st of each month (or next business day).Two options are available for auto pay, choose either: 1) ACH debit payment from a checking/savings account, or 2) by credit/debit card. Autopay is not required; sign up at any time, now or later.
AutoPay*

I want to sign up for AutoPay. Please contact me.I do not want to set up AutoPay.
Please verify that you are human*
Should be Empty:

Internet Service

Internet Security Service

HomePass By Plume

Customer Proprietary Network Information

CPNI Authorization

Authorized Account Users

Terms and Conditions

AutoPay