Application for Telephone Service

CUSTOMER INFORMATION:

Name:
Contact Number:
Billing Address:
City:	State: Zip:
Type of Service:	Residence Business
Please choose if: Published Non-Pub (addt'l chg) Non-List (addt'l chg)

Location of Service:

Urban: Street Address

Rural:Township

Section

Range

Fire #

Name and address as you'd like it to appear in the directory:

CREDIT INFORMATION:

Previous Telephone #	Disconnect Date	Social Security Number
Applicant grants permission to use credit reporting agency information should utility references be unavailable. Yes No

Employer's Name:
Employer's Address:
City:	State: Zip:
Employer's Phone:

PRODUCT INFORMATION / TYPE OF SERVICE:

Dispatch Technician to Premise ($50/hr chg applies) ? Yes No
Describe

Long Distance Carrier:	InterLATA	IntraLATA
Pic Freeze?	Yes No

Convert or New Toll-Free #?

Yes No

If Yes,

Number

Carrier

Do you need Calling Cards? Yes No
Pin Number

Comments:

Check those you want: - Click here for descriptions and pricing.

Custom Calling Features

CSR Initials

Call Fwd	Call Waiting	8# Speed Dial
30# Speed Dial	900# Block (N/C)	Toll Control w/ Pin $2.75)
3-Way Calling	Deny Collect Calls (N/C)	Deny 3rd Party Billed Calls (N/C)

Class Services

Caller ID	Caller ID Deluxe	Caller ID Block (N/C)
Caller ID w/ Call Waiting	Caller ID Deluxe w/ CW	Automatic Callback
Automatic Recall	Voice Mail - w/ busy line $1 addt'l

Wire Maintenance:	Self OTT
(Res=$1/line, Bus=$2/line)	Covers wiring from demarc to customer premise equipment.

Under the penalties of service disconnection or immediate deposit request, I declare that I have examined and completed this application and the information I have given is true, accurate and complete. I will assume all responsibility for all charges for this phone service. I agree to the rules and regulations of Otter Tail Telcom as set forth in the Exchange Tariff and to any general changes in the rules, regulations, tariffs or rates for the service furnished under this application.
This application authorizes Otter Tail Telcom to act as our communications agent when dealing with US West. We authorize Otter Tail Telcom to obtain information and/ or copies of all our network services and to order and manage all negotiations for the installation of telecommunications services. This authorization shall remain in effect until canceled by us in writing. This letter of agency rescinds any other letter of agency previously entered into.


	I agree to the terms and conditions of the application for telephone service, etc.