Panora Telco:Internet Registration Form

114 East Main Street
Panora, IA 50216
641-755-2424
panora@netins.net

Panora Cooperative Telephone Application for Service

Date:____________________________________________________________________________________

Business Account:

Residential Account

Assigned Phone: ________________________

Applicant/Shareholder:

____________________________________ SS#___________________________

Name of Business:

____________________________________

Spouses Name (Residential)

____________________________________ SS#___________________________

Directory Listing

Service Address

__________________________________State __________ Zip _____________

Mailing Address

__________________________________State __________ Zip _____________

Present Telephone No.

(______) __________________________ Telephone Co.____________________

Block 900 Numbers

Yes

Comments:

___________________________________________________________________

Employer:

__________________________________ Emp. Phone No. ____________________

Employer's Address

__________________________________State __________ Zip _______________

Name and Address of Close Relative:

____________________________________________________________________

Registration cannot be processed if the above is not filled out completely

Wiring Agreement

YES: I want the Panora Communications Cooperative to maintain the inside wiring of my telephone service at 50 cents per month. (Not available if wiring done by outside contractor).

NO: I do not want the monthly service agreement. I will be responsible for the maintenance of inside wiring, or will ask Panora Communications Cooperative to maintain it at $30.00 per maintenance visit, plus time and materials.

In making this application the undersigned agree to the rules and regulations of the Telephone Company as set forth in the exchange tariff, and to any general changes in rules, or rates for the service furnished under this application. This application becomes a contract wen accepted in writing by the Telephone Company.

Date of Service: ____________________Applicant/Shareholder Signature:

______________________________________________________________

If applicant's credit rating is found to be unsatisfactory, a larger cash deposit will be required.

******************************* OFFICE USE ONLY *******************************

Installation	$9.63
Membership	$10.00
*Deposit	$25.00
TOTAL	$44.63

Former Resident: ______________________________



Share No. ___________________
*With deposit some exceptions may apply

Touch Tone_________________________________

Lease Equipment____________________________

Customer Owned Equip._______________________

Call Waiting_________________________________

Call Forwarding______________________________

Speed Dialing (8)_____________(30)____________

Conference Calling___________________________

Toll Restrict_________________________________

Non-published______________________________

Toll Carrier (641)____________________________

Toll Carrier (Outside 641)______________________

Circle your choice for your long distance carrier

Telephone Number: ___________________________________________ Date: _____________________________________________

Signature: ___________________________________________________

For Office use Only

For Office Use Only:		New Install _____	Pic Change _____	Completion Date:	_____________________
		CSR Tech ______________________

WA___ INS___ 901___ 902___ PTLD: 14c___ - USP341 ($2.95)___Calling Plan: 10c___ - USP320

Request for Preferred Carrier Freeze Billing:

Name:____________________________________________________________

Address:________________________________________________________________

City:______________________________ State:_____________ Zip Code:__________

Please check the service(s) you would like to have frozen with respect to each one of your telephone number(s). If you have more than one telephone number you need to write down each number and the service you want the freeze on.

Telephone Number: ______________________________________________________

Local Service_________ All Long Distance Service: Intra____ Inter_____

(If you have more than one telephone number then please mark the additional lines below).

Telephone Number: 2^nd line _______________________________________________

Local Service_________ Long Distance Service: Intra____ Inter____

Telephone Number: 3^rd line _______________________________________________

Local Service_________ Long Distance Service: Intra____ Inter____

Telephone Number: 4^th line _______________________________________________

Local Service_________ Long Distance Service: Intra____ Inter____

Signature:____________________________________

Print:________________________________________

Date:_________________________________________

( Please call (641) 755-2424 if you have questions about this form)