Please review all of the items listed below. Any form errors will appear at the bottom of the page. All checkboxes listed are required. Would you like to add a phone line Yes, I would like a phone line. No phone line please. PHONE FEATURE CHOICES: Call Forwarding Caller ID Name & Number Call Waiting 3-Way Calling Telemarketer Screening Voicemail Teen Line Toll Control Please select an internet Package 100 Mbps | 250 Mbps | 500 Mbps | No Internet Cable Package Basic Cable TV Expanded Cable TV No Cable TV Would you like any additional channels HBO Showtime Cinemax Starz/Encore Applicant: Responsible for account Driver’s License # Daytime Contact # Email Address Co-Applicant: Responsible for account I will have a Co-Applicant with this account. Driver’s License # Daytime Contact # Email Address Account Security Information: (to access account information) Password City where you were born? Daytime Contact # What is your favorite color Additional Authorized Contacts: Additional Authorized Contact: Additional Authorized Contact: Installation Information Have you had service with us before? No Yes Address Service Requested At: Billing Address: Payment Information I want to set up automatic payments Name on Account: Account Number: Routing Number:
