Western Iowa Telephone

Cable Television Application

Name:
Service Address:
Mailing Address (if different):
Telephone Number:
Social Security Number:
Please mark the services you would like:
	Basic Cable TV $32.95
	HBO, HBO 2, HBO Signature, HBO Family $13.95
	Showtime, Showtime 2, TMC, FLIX, and the Sundance Channel $13.95
	I need wiring done for additonal cable locations. Charges will be $50 for first location and $35 for each additional cable location.
	Digital Cable TV $18.95
	Digital Cable TV with DVR $24.95
	Extra set-top box $7.00 (Please state how many you would like)
	Extra DVR $13.00 (Please state how many you would like)
	Digital HBO $14.95
	Digital Cinemax $11.95
	Digital Showtime $14.95
	Digital Starz & Encore $13.95
	Digital Spanish Package $2.99
	Digital High Definition Package $9.95
Please call our office for an amount to send with your application. (944-5711) I 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 conditon as received, I will pay the dollar amount that has been relayed to me by a Western Iowa Telephone customer service representative. (Please fill in the amounts that they have told you over the phone and write in the number of each piece of equipment that you will be needing in the boxes before each item.) High Def Box $_________________________ Hi Def DVR Box $_________________________________ Model ____________________________________ Model_______________________________________________ Serial #____________________________________Serial #______________________________________________ Power Cord $_________________________ Remote Control$__________________________________ Audio Video Cables $________________________________ signature $25 One-time Installation fee applies for Basic Cable TV. Digital and High Def services are currently being offered with no installation charges during the promotional period.