RTC COMMUNICATIONS
PO Box 9 (812)
486-3211
Montgomery, Indiana 47558 (800)
272-2356
www.rtccom.net Rev. 5/02 Fax (812)
486-3004
INTERNET ACCESS ACCOUNT APPLICATION
PERSONAL INFORMATION
YOUR NAME:________________________________________ PHONE #:______________________
ADDRESS:___________________________________________
CITY:_______________________
STATE:_______ ZIP:________ SOCIAL SECURITY # (For Identification Only):___________________
SPOUSE/OTHER:______________________ SOCIAL
SECURITY #:____________________________
(This person will be authorized to make changes or request information concerning this account)
ACCOUNT INFORMATION
Choose a
Username....this will be part of your e-mail address:
(Minimum of 5 characters, maximum of 8
characters, must be lowercase)
1st Preference:
____________________________ 2nd Preference: ____________________________
Choose a password...this
is for security purposes:________________________________________
(minimum of 5 characters, maximum of 8 characters, (combination
of numbers & letters is best)
SERVICES OFFERED (choose one)
_____Unlimited
Access $19.95/month
_____Unlimited Access
$18.95/Daviess Martin Rural Telephone County Member
Your monthly Internet access charges will be added to your telephone bill
Do
you want email filtering at no charge? YES NO
* Prices are subject to change in accordance with the terms and conditions.
METHODS OF PAYMENT: (choose one)
____Monthly Billing: Invoices will be mailed the first of the month. Due by the 17th.
____Yearly Billing: Get 12 months of access for the price of 11 with yearly billing. ($219.45)
___ EZ-PAY Have your
monthly Internet access direct debited from your checking or savings account.
Please ask for
our authorization form. ($2.00 discount applies)
AUTHORIZATION
I have read all pages of this document in their entirety and agree to the terms and conditions within. I further agree that RTC Communications can in no way be held responsible for the suitability to minors of any material contained on or obtained through any of its services. I affirm that I am legally qualified to contract and have attained the age of at least 18 years.
Signature:_______________________________________
Date:____________________________