Internet Application for Dial Up or High Speed DSL
Name:
Business Name (if applicable)
Address
City:
State:
Zip:
Home Phone:
Daytime Phone:
Billing Address (if different):

Primary e-mail (15 Characters maximum)

Additional e-mail #1 Real Name

Additional e-mail #2 Real Name

Additional e-mail #3 Real Name

Additional e-mail #4 Real Name

Mother's Maiden Name: (Needed for password security)

Please indicate system type: (ex. - Win2000, Win95, XP)

Choose which service you would like:

Dial-Up for $15.95/month for Telephone customers

Anthon & Onawa Dial-Up for $19.95/month

Accelerator first month is a free trial; $3/month thereafter

No activiation charges. (800 number access available through netINS) (A $50 cash deposit may be required based on credit history)


No activation charges

 

No activation charge for Accelerator.

SecureIT free trial for first month; $7.95/month thereafter. No Activation charge for SecureIT Antivirus protection. Additional computers may be covered for just $5/month. Write the number of services you need in the box.

 

Basic DSL for $39.95/month(with phone service) with speeds up to 1.5 Mbp.

Basic DSL without phone service for $64.95/month.

Premier DSL for $49.95/month with speeds
up to 3 Mbps.

Business DSL for $79.95/month with speeds up to 4 Mbps downstream & 2 Mbps upstream.

 

No activation charges. External modem is provided at no additional charge, but the modem remains the property of Western Iowa Telephone and must be returned if DSL is disconnected for any reason.. (This service is available for members only. Prices and availability are subject to change without notice. All charges are subject to taxes and Federal Universal Service Charges.)
Contact our customer service reps for pricing on activation charges for all three levels of DSL service without telephone service.

 

No activation charges.

 

No activation charges.

Do you currently have a WITA dial-up account?

 Yes No

If your answer is yes, would you like to keep dial-up
access for $10.00 per month?

Yes No
Do you have a 2nd line you wish to disconnect once DSL is in? Yes No
I have a 2nd line, but I wish to keep it for a teen line. Yes No
If you wish to disconnect this 2nd line, what is the telephone number?
Do you have either a 10 base-T Ethernet adapter or Network Card?(Service will not work without it) Yes No
Do you need a new jack installed near your computer? (If so, additional charges will apply) Yes No
Do you need a static IP address for a one-time charge of $50? Yes No

Your Signature:

By signing this application, I am agreeing to keep this DSL service for a minimum of 12 months. Charges may apply if service is disconnected prior to the end of the 12-month period.

If this is a DSL application, I further acknowledge receipt of the equipment listed below from Western Iowa Telephone. I understand the listed equipment remains the property of WITA, and upon termination of my service for any reason, I agree to return the listed equipment to WITA in the same condition as it was received. I further understand that if the listed equipment is lost, stolen, damaged, destroyed or not returned for any reason in the same condition as received, I will pay the dollar amount for the listed equipment as expressed to me by a WITA customer service representative. Please fill in the blanks with the proper amount.

DSL Modem & Power Cord $________________________________

Your Signature:

Date:

© Copryright 2005 Western Iowa Telephone