Residential Application for Service
Date: _______

Employee Initials: ____
Comlpete Name ______________________________________________________________________________
  First Middle Last
Address ____________________________________________________________________________________

SS# _______________________ SS# ______________________ Email Address __________________________

Current Phone Number (s):
_____________________
_____________________

Directory/Name:
___________________________ ( ) Listed ( ) Unlisted
___________________________ ( ) Listed ( ) Unlisted
Porting? Yes or No    If yes, we need a signed Letter Of Agency. (Customer will receive a free intercept message for 30 days)
   
Current Employer: ___________________________ Employer's Ph # ______________________________
   
Basic Phone Service Per Month:  
Residential - 1st Line ...................................................................................................... $12.00 Per mo. plus tax
Residential - Additional Lines .......................................................................................... $9.00 Per mo. plus tax
   
Long Distance Phone Service: Choose Long Lines Long Distance and get toll-free calling to Long Lines phone customers in Anthon, Holstein, Ida Grove, Sgt Bluff, Salix, Sloan, Soldier, Moorhead, Mapleton, Orange City, Onawa, Whiting, Danbury and Dakota Dunes, & Jefferson, SD.
Flat Rate - 9.5 cents per minute In-State and Out-of-State - No Monthly Fee
Basic Savings - 9.5 cents per minute In-State & 6.5 cents per minute Out-of-State - $3.95 monthly fee
Other __________________________________________________________________________________
PIC Freeze: I request Long Lines to place a PIC Freeze on my phone number(s)
   
Internet Service
$21.95 - Dialup
$39.95 - High Speed Internet

Modem # issued: ___________________________
SecureIT:    Yes    No
Postini:    Yes    No

Username: ________________________________
(at least 3 characters, no maximum characters)
Password: ________________________________
(6-8 characters with at least one capitle ltr or number) 		Cable TV
Basic Cable TV - $28.95
HBO Pkg - $14.95
Showtime Pkg - $14.45
Combo Pgk (Includes HBO & Showtime Pkg) - $26.95
Digital Cable - $12.95
Digital Cable with DVR - $18.95
Each add'l Digital Box - $7.00
Each add'l Digital Box with DVR - $13.00
Cinemax on Digital - $11.95
Starz/Encore on Digital - $13.95
High Definition - $9.95
   
$1.00 off if entire bill paid by ACH (Automatic Check Handling)
   
This application for service shall be in affect upon the receipt and acceptance by Long Lines. I certify that I am at least 18 years of age and that I have the authority to sign this application.
  Signature ____________________________________