RESIDENTIAL SERVICE APPLICATON

Hopi Telecommunications Inc
PO Box 125
Keams Canyon, AZ 86034
928-738-4674
www.hopitelecom.com
RESIDENTIAL SERVICE APPLICATON
PERSONAL INFORMATION
FULL NAME

First NameLast Name
SOCIAL SECURITY #
BIRTHDATE

MonthDayYear
Date
BILLING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHYSICAL ADDRESS

Street Address

Street Address Line 2

Village/CommunityState / Province

Postal / Zip Code
PHONE #
Format: (000) 000-0000.
EMAIL
example@example.com
EMAIL BILLING
CONNECTION INFORMATION
HAVE YOU EVER HAD AN HTI ACCOUNT?
HAS THE HOME EVER HAD SERVICE?
IF THE HOME HAS NEVER HAD SERVICE,
A SERVICE LINE AGREEMENT MAY BE NEEDED
NEAREST NEIGHBOR WITH SERVICE
SECURITY DEPOSIT
CUSTOMERS MAY BE SUBJECT TO A REFUNDABLE DEPOSIT OF: $55.00
AFTER 12 MONTHS OF GOOD PAYMENT HISTORY, NO DELINQUENT NOTICES OR DISCONNECTS
THE DEPOSIT WILL BE CREDITED BACK TO CUSTOMERS ACCOUNT WITH ANY INTEREST GAINED
LIFELINE APPLICANT
IF APPLYING FOR LIFELINE,
NO SECURITY DEPOSIT IS REQUIRED
CPNI Required Security Question
SELECT ONE QUESTION
ENTER ANSWER HERE
ADDITIONAL INDIVIDUAL(S) 18YRS+ TO BE AUTHORIZED ON ACCOUNT TO GET INFORMATION
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
TELEPHONE SERVICE
BASIC TELEPHONE SERVICE (LOCAL CALLS ONLY): $28.50/MONTH
TELEPHONE REQUIRED FOR BROADBAND SERVICE
*HTI DOES NOT PROVIDE LONG DISTANCE SERVICE.SERVICE CAN BE SET UP WITH THIRD-PARTY CARRIER
COVERS WIRING UP TO THE JACK. DOES NOT COVER CUSTOMER CAUSED ISSUES, CUSTOMER EQUIPMENT, MODEMS OUT OF WARRANTY OR ACTS OF NATURE.
BROADBAND PLANS

Rows	SELECT ONE
ESSENTIAL $45 15MBPS DOWNLOAD/3MBPS UPLOAD (COPPER ONLY)
BASIC $55 25MBPS DOWNLOAD/3 UPLOAD (COPPER & FIBER)
STANDARD $65 50MBPS DOWNLOAD/25MBPS UPLOAD (FIBER)
ENHANCED $80 100MBPS DOWNLOAD/50MBPS UPLOAD (FIBER)
PREMIUM $125 300MBPS DOWNLOAD/100 MBPS UPLOAD (FIBER)

MODEM CHARGES
MODEM COST: $125
THE MODEM IS UNDER WARRANTY FOR TWO YEARS FROM ORIGINALDATE OF INSTALLATION. IF MODEM IS DEEMED TOBE DEFECTIVEWITHIN WARRANTY PERIOD HTI WILL REPLACE AT NO COST
DISCLAIMER
SERVICE AND SPEED IS NOT GUARANTEED. SOME FACTORS OUTSIDE OF HTIS CONTROL MAY CAUSE VARIATIONS WITH SERVICE.
NO COMPENSATION WILL BE PROVIDED FOR CIRCUMSTANCES OUTSIDE THE AUTHORITY OF REGULAR OPERATIONS.
THE MODEM HTI INSTALLS ENSURES EFFECTIVE TROUBLESHOOTING.
SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

RESIDENTIAL SERVICE APPLICATON

PERSONAL INFORMATION

CONNECTION INFORMATION

SECURITY DEPOSIT

CPNI Required Security Question

ADDITIONAL INDIVIDUAL(S) 18YRS+ TO BE AUTHORIZED ON ACCOUNT TO GET INFORMATION

TELEPHONE SERVICE

BROADBAND PLANS

MODEM CHARGES

DISCLAIMER