Application for Service - East Buchanan Telephone Cooperative 
Name on Account: _____________________________   Birthdate: _______________________
Address: ____________________________________   Soc. Sec. No._____________________
_________________________________________________  Cell Phone No.____________________
Billing Address: ____________________________________   Circle One:    Rent           Own
_________________________________________________   Eligible for LinkUp Iowa:    Y     N
Previous Address: __________________________________________________________________
Previous Phone: ____________________________________  Previous Member of EBTC?   Y     N
Present Employer: __________________________________   Phone No.______________________
Employer Address :_________________________________________________________________
Spouse's Name: ___________________________________    Soc. Sec. No._____________________
Spouse's Birthdate:_________________________________    Cell Phone No.___________________
Spouse's Employer: __________________________________ Phone No.______________________

Employer Address :_________________________________________________________________

Authorized Users on Account:_________________________________________________

Password for Account Inquiries: ______________________________________________

Answer to the Back-Up Question:     (What is your favorite color?)     ___________________     

E-mail Address for Account Inquiries:  __________________________________________
Assigned Phone No._____________________ Do you want your number:     LISTED       NON-PUBLISHED
Choice of Long Distance Carrier: ___________________________________________________
Do you want the Preferred Carrier Freeze on your accounts?    Yes        No      (circle one)

Custom Calling Features: (Please circle features you would like)

Caller Name Call Waiting Call Forwarding Speed Calling
Caller Number Automatic Recall *69 Three Way Calling       900 Call Blocking

              FREE      ONLINE CUSTOMER CARE            PASSWORD:________________________

             FREE                 EBILL                                   EMAIL ADDRESS:________________________

East Buchanan Telephone Cooperative is an Equal Opportunity Provider.

Permanent Resident who can furnish us with your current address in the future so you can receive any dividends to be refunded:

Name: _____________________________________________Relationship:___________________

Address: _________________________________________Phone No. _______________________
*****PICTURE ID REQUIRED*****
Because the telephone company is a recipient of Federal Funds, it is required to ask the following questions to meet Title VI regulations. How would you like the telephone company to answer the following?

Which of the following is your racial/ethnic category? (Circle One)

  • White
  • Black or African American
  • Hispanic or Latino
  • American Indian/Alaska Native
  • Asian
  • Native Hawaiian or Other Pacific Islander

In making this application, the undersigned agrees to the rules and regulations of the Telephone Company as set forth in the Exchange tariff, and to any general changes in rules or rates for the service furnished under this application. If any misinformation is given above, disconnection and/or a cash deposit will be required. If applicant's credit rating is not found to be satisfactory, a cash deposit will be required. Once delinquent, customer will be responsible for any collection costs associated with the recovery of the debt. Disconnection of any and all services may occur if you have a debt with any East Buchanan service that we offer, such as I Wireless.

APPLICANT'S SIGNATURE:________________________________________  Date: ________________________

************************FOR OFFICE USE ONLY**************************
MEMBERSHIP REQUIRED $10.00   MEMBERSHIP NUMBER ________________
TELEPHONE SERVICE

--------------------------------------  LINK-UP IOWA CUSTOMERS:   
Installation Fee $20.00      ---------------------------------               $10.00
Minimum Deposit (required) $50.00   ---------------------------  Deposit to be paid in 12 mos. time
INTERNET SERVICE

(Not eligible for Link-Up)        Deposit may be required

                                              = 2 mos  service  $_____________
What type of Internet service?                              (See Internet Application)
DIAL UP
256 DSL
512 DSL
1 MG DSL
3 MG DSL
$19.95
$34.95
$39.95
$49.95
$64.95
CATV SERVICE

(Not eligible for Link-Up)       Deposit required  $100.00                         
Installation Fee $25.00
Basic Cable $47.95                      
3 - HBO Channels $13.95                      
TOTAL AMOUNT TO BE PAID WITH APPLICATION:   $___________    CASH      CHECK
Switch:__________________ INS:____________________ ILLUMINET:_______________