Local Phone Service Application


Customer Information
Customer Name
Service Address
City
State
ZIP
County
Daytime Phone
Cellular Phone
Email address
Billing Address
Social Security #
Drivers License #
Account Password (To verify account information)
Date Service is Requested

Available Calling Features

Call Waiting: $2.50
Wire Maintenance Agreement: $0.75
Call Forward: $2.50
Voice Mail: $2.95
Caller ID: $5.00
Speed Dialing: $2.50
Caller ID w/Call Waiting: $9.00
3 Way Calling: $2.50

Long Distance Carrier and Calling Plan (See Long Distance Plans)

Toll Restrict - Yes
Toll Restrict - No

Directory Listing (Please Circle)

Published
Non-Listed: $1.25
Non-Listed/Non-Published: $2.50
It is my understanding that before disconnection of residential service for non-payment, the County Dept. of Health and Social Services will be notified if I or another responsible party request in writing that Amery Telcom (Northwest Communications) notify the agency.

In order to provide telephone service to subscribers, it is my understanding that I will be allowing telephone facilities and personnel on my property if owned by myself, or will get approval from the owner. I agree that any leased equipment is the property of the Telephone Company, shall be subject to monthly rental charges, and shall be returned in good working condition upon termination of service.

In making this application, I agree to pay the bill in a timely manner and follow the rules and regulation as established by Amery Telcom or its subsidiary and to any general change or changes in the rules, regulation, tariffs or rates for the service furnished under this application and any other changes approved by the Wisconsin Public Service Commission. All prices are subject to change.


Customer Signature __________________________________

Date __________


Northwest Communications
120 Birch St W
Amery, WI 54001