RC Application

Name*

First NameLast Name

Primary Contact*

Phone Number*

(###)###-####

Email*

example@example.com

Driver License #*

Address*

Street Address

Street Address 2

CityState

Zip Code

County*

Mailing Address

Street Address

Street Address 2

CityState

Zip Code

Is this a rental property? If yes, please fill out rental information on the Utility Form.*

YesNo

Do you live on a private drive?*

YesNo

Will an easement be necessary to install your service?*

YesNo

Do you need a phone line?*

YesNo

Do you want to keep same phone number?*

YesNo

If yes, what is your existing phone number?

Do you want your phone number published/Non-published?*

PublishedNon-Published ($1.50/mo)

List in Directory as

Authority to perform credit check*

YesNo

Choose Your Internet Only Plan: (Wire Maintenance is required $2.95/mo.)*

300Mbps/300Mbps - $77.95600Mbps/600Mbps - $97.951GIG/1GIG - $137.95

Choose Your PHONE/INTERNET Bundle: (Includes Unlimited Calling) Taxes and fees not included.

Equipment (Required)*

Do you want Voicemail?*

YesNo

How many rings before voicemail answers?

Agreement Relating to Identification of Utility Equipment and Other Equipment and Devices

I (We) agree to (Select one)*

Schedule a meeting with a company representative so that I (we) can identify and locate any equipment, structures, or devices which employees or agents should be made aware of before they commence performing work or services on my (our) premises.Waive the meeting with company representatives and my (our) opportunity to identify and locate any equipment, structures, or devices described above, and thereby hold Randolph Telephone Telecommunications Inc., company representative, and agents harmless and free of any liability resulting from damage or destruction to any equipment, structures, or devices which would not be apparent to a reasonable person.

Check any items that you believe exist on your property:

Residential Application