Farmers Telephone Company Service Application "*" indicates required fields Section One - Customer InformationBusiness or Residential?*Is this inquiry for a Business or Residential Agreement? Residential Business Contact Name* First Last Date of Birth*Your DOB and SSN are encrypted upon submission and stored on our secure servers. Alternatively, you may choose to provide your SSN in person for added convenience and security. Social Security NumberYour DOB and SSN are encrypted upon submission and stored on our secure servers. Alternatively, you may choose to provide your SSN in person for added convenience and security.Please enter a number from 0 to 999999999.Contact Email*For Customer communication only. We do not sell or share contact information. Enter Email Confirm Email Contact Phone Number*Address* Street Address City State Zip Code Do you own or rent the property where you are requesting service?* Own Rental CPNI Password Set UpUnder the new FCC rules governing the use and disclosure of Customer Proprietary Network Information (CPNI), there are certain circumstances under which Farmers Telephone Company LLC may be permitted to respond to your inquiries regarding call detail information or certain account information only by the customer providing a pre-established password, the company calling the telephone number listed on the account, or the company sending such information to the mailing address or electronic address of record.PasswordConfirm PasswordSecurity Question: What is your favorite color?Section 2 - Internet Service **Availability varies by location.** Farmers Telephone Company/Heartland.net Fiber and Wireless connections are NOT available in all areas. Fiber Internet Speed ChoicesPlease select the desired Fiber Internet Speed. Not all speeds are available in all locations. 100 Megabit (Mbps) - $59.95 200 Megabit (Mbps) - $99.95 1 Gigabit (Gbps) - $249.95 Wireless Internet Speed ChoicesPlease select the desired Wireless Internet Speed. Not all speeds are available in all locations and a wireless internet connection requires a sight survey. 10 Megabit (Mbps) - $39.99 20 Megabit (Mbps) - $69.99 50 Megabit (Mbps) - $49.95 (Clarinda's Only Choice) 100 Megabit (Mbps) - $79.95 Lease Router - $4.95/month (Wireless Only)Please select if you would like to lease a router through FTC. Yes No - I have my own. Section 3 - Telephone ServiceEssex Residential Phone Minimum Charges - $28.00 Per Line + Taxes & Fees Unlimited Long Distance Residential - Additional $20.00 Unlimited Long Distance Business - Additional $40.00 Pay As You Go Long Distance - Additional $ 0.13 - $ 0.15/Min Phone Outside of Essex (Rural Fiber Only, Not Available For Wireless Connection)Unlimited Long Distance Included Residential Phone - $30.00 Per Line + Taxes & Fees Business Phone - $35.00 Per Line + Taxes & Fees Fax Lines - $35.00 Per Line + Taxes & Fees Type of Phone Lines Needed Residential Business Quantity of Phone Lines NeededWish to keep existing numbers? Yes No If Yes, please list numbers to Port.Section 4 - Television ServiceFiber Only. Not Available to Wireless Customers.Television PlansPlease select one Television Package. Acclaim Lite - $50.99 Acclaim Choice - $93.99 Acclaim Choice+ - $98.99 Prime - $155.99 Prime+ - $160.99 Set Top Boxes / DVRSet Top Boxes - $6.00/month per TV DVR - 100 Hours $12.00 / month and Additional 100 Hours $5.00 each. One-Time $25 TV Installation Fee per TV. Need DVR Services Movie ChannelsSelect any additional channels that you would like to add. HBO - $20.00 Cinemax - $14.00 Starz - $12.00 Showtime - $11.00 Starz + Encore - $17.00 Encore - $7.00 Prime Sports Package - $8.99 Prime+ Sports Package - $5.99 Section 6 - SignatureAll customer proprietary network information (CPNI) is kept confidential. Notice* Signing this agreement does not guarantee services. Our office will contact you with available installation dates and times as well as information regarding services available at your address. Upon cancellation of service the customer is required to return all Farmers Telephone Company/Heartland.net equipment. Failure to return equipment will result in a $300.00 equipment charge. I have read and understand.Customer Signature*Initial Here*Date Signed