Qualified residential customers only. Does not include applicable taxes, surcharges, and fees; which are subject to change. The $99 standard installation, ...
Internet and Phone Packages.
Direct Fiber Residential Package Application Customer Information [Existing MIDTEL Customer? ___ Y or ___ N] Name(s): _______________________________________________________________ (Please provide copy of Photo ID) Service Location: ______________________________________________________ Driv. Lic. #: _______________________ Mailing Address: ______________________________________________________ SS#: _____________________________ Phone : ___________________________ Mobile: ____________________________ Daytime: _________________________ Email Address: ________________________________________________________ New # Assigned: __________________ For Office Use Only Is your service? Aerial: ____ or Buried: ____? | If buried, is there conduit: _____? | Approx. Distance: _____________ Internet, TV and Phone Packages Enhanced .................... $120.95/mo* Advanced .................... $165.95/mo* Ultimate .................... $205.95/mo* Internet and TV Packages Enhanced .................... $ 99.95/mo* Advanced .................... $139.95/mo* Ultimate ..................... $169.95/mo* Internet and Phone Packages Enhanced .................... $ 81.95/mo* Advanced .................... $111.95/mo* Ultimate .................... $141.95/mo* Internet Only Packages Enhanced .................... $ 60.95/mo* Advanced .................... $100.95/mo* Ultimate ..................... $130.95/mo* Installation Charges*: PreInstallation Site Survey is required. Aerial Fiber Drop Install: Up to 300ft...$49 | 301-500ft...$250 | 501-1,000ft...$500 | 1,000ft+...$1,000 Buried (Existing Conduit): Up to 300ft...$99 | 301-500ft...$350 | 501-1,000ft...$1,000 | 1,000ft+...$1,500 Buried (New Conduit)**: Up to 300ft...$250 | 301-1,000ft...$250 PLUS $5.00/ft for footage over 300ft ** Locate Charge may apply and vary based on situation. Handhole(s) if needed are $250 each. Conduit may be purchased for self-installation at $2.00/ft. Any new buried conduit 1,000ft+ must be installed by the home owner or contractor. MIDTEL will provide contractor recommendations upon request. When performed by the home owner, it must be inspected by MIDTEL before backfilling. * Qualified residential customers only. Does not include applicable taxes, surcharges, and fees; which are subject to change. The $49 standard installation or calculated installation charge includes the installation of aerial or buried fiber optic cable to your home and the set up of the services included in the selected package. Additional services available at current retail rates. Unlimited long distance includes calling to the United States & the District of Columbia. By signing this form I agree to authorize a credit check, all terms, conditions and acceptable use policies, set forth by MIDTEL, which can be found at www.MIDTEL.com. 103 Cliff Street, PO Box 191, Middleburgh, NY 12122 | Email: sales@midtel.com | 518.827.5211 | Fax: 518.827.7600 Revised 7/20/21 Digital Telephone Porting your existing landline number?: Phone #: ______________________________ Current Provider (if not MIDTEL): _________________________________ (Copy of recent phone bill required) Would you like the Phone Number Listed? or Non-Published? ($0.63/mo additional) Directory Name: ________________________________________________________ Same as Customer Name: Call ID Display Name (15 characters - includes spaces): ____________________________________________ Do you Own or Rent? __________ If Renting, Landlord name: _____________________________________ (Please note: A residential telephone service will be reclassified to business service if used for business purposes, or if the telephone number is advertised in connection with the sales of products or services.) Additional Inside Wire Installation I would like MIDTEL to install my Telephone Inside Wire. The following charges will apply at the time of the package installation: $25.00 per additional phone. Number of jacks required? _______ I do not need to have any Inside Wire installed. Maintenance MIDTEL offers Inside Wire Maintenance for $2.00 per month per telephone line. This service covers all telephone inside wire and telephone jacks. It is optional and can be added or discontinued at anytime. Please ask for any questions or details. Yes, I would like the Inside Wire Maintenance Plan No, I will maintain the Inside Wire myself Call Restrictions I hereby request that the following call restriction(s) be placed on my telephone number: Non-Chargeable Restrictions Robo Call Filter 900 Area Code Calls Third Party Calls Collect Calls Chargeable Restrictions All Long Distance Calls* International (country code only calls) Include Caribbean Include Canada Other (specify) All Call Restrict Per Call Restrict (default) (Note: Calls to 911, toll free numbers, & 900 numbers will transmit the calling number and are NOT capable of being blocked.) *Casual Call (10-10 calls) will only be blocked by requesting an All Long Distance Calls Restriction. Non-Recurring Charge (Waived on New Installation)......$25.00 Monthly Recurring Charge...................................$ 3.00 Calling Features Voicemail Optional Add-Ons One Time Installation Charge (Waived on New Installation) .............................................$25.00 CC3 (Call ID/Waiting/Forward)...$5.00/mo Call ID ..........................................$4.00/mo Call Waiting .................................$3.00/mo Call Forwarding ...........................$2.00/mo Three Way Calling........................$2.00/mo Distinctive Ring...........................$4.00/mo Other ________________________________ Small (10) 30-Second Messages ....... $3.95/mo . Medium (20) One-Minute Messages .................................................... $4.95/mo Large (25) Two-Minute Messages ..... $5.95/mo X-Large (30) Three-Minute Messages .................................................... $7.95/mo Voicemail to Email Feature (No Charge) Email: ________________________________________ Cable Television Please choose additional programming that you wish to receive below. High Definition (HD) programming requires both an HD Set-Top Box and an HD Television. Equipment Selections Email Address for TiVo: ________________________________________ (You will need this same email when signing up for the Vu-It App) Same as Main Email: Install to # TV's Analog: _______ Digital: _______ HDTV: _______ Additional Installations at Time of Install First TV...................................................... $50.00 Each Additional TV .......................... $25.00 Move to New Location ............................... $50.00 Each Additional Move ...................... $25.00 Additional Set-Tops Each set-top includes a remote control _______ Motorola HD-DVR Set-Top Box ..................... $ 6.95/mo/set-top _______ TiVo T6 HD-DVR Set-Top Box ...................... $14.95/mo/set-top _______ TiVo Mini HD Set-Top Box............................ $ 6.95/mo/set-top _______ Additional Remote Control........................... $ 1.00/mo/remote Package Upgrades Premiums HBO.....................................$14.99/mo Cinemax...............................$14.99/mo Showtime.............................$14.99/mo Starz & Encore.....................$14.99/mo Premium Suite.....................$48.95/mo Tiers Lifestyle ............................ $3.95/mo Lounge............................... $3.95/mo Lifestyle & Lounge ............ $6.95/mo Adult Channels Playboy .............................. $17.95/mo Reality Kings..................... $19.95/mo Bang U. ............................. $19.95/mo Brazzers............................. $19.95/mo Miscellaneous Damaged/Unreturned Equipment Motorola HD-DVR Set-Top Box......$250.00 TiVo T6 HD-DVR Set-Top Box.....$500.00 Motorola Digital Set-Top Box........$100.00 TiVo Mini Set-Top Box................$250.00 Inside Wire Maintenance............$2.00/mo (Coaxial Cable Only) High Speed Internet Please fill in the following information and select any additional services. If you have any questions please ask a representative. Wireless Router & Computers Choose one..... MIDTEL Provided Wi-Fi (included in package) Wi-Fi Network Information Network Name: ______________________________________ Or... Password: ____________________________________________ (Please use as least 8 characters. Special characters are limited to: at symbol @ , exclamation !, and underscore _ ) I have my own router... Model: ____________________________ Router must support PPPoE MIDTEL does not support Customer Provided Equipment (CPE). Installation Set-up & Premise visits related to CPE will be charged at current labor rates. How many computers of each would you like hooked up? Desktop: ____ and/or Laptop: _____ Do you need a Static IP Address? No: ____ or Yes: _____ ($5.00 monthly charge per Static IP) Please note: Windows 95 through XP are no longer supported or installed by MIDTEL. Mac requires OS 8 or newer. MIDTEL Email Addresses - If Desired Please choose a Username and Password that you would like for email - if desired. Username: __________________________________ Password: ___________________________________ Username: __________________________________ Password: ___________________________________ Username: __________________________________ Password: ___________________________________ Note: Please use at least 10 characters for Usernames & Passwords. Usernames and Passwords cannot contain the same name or phrase. The "."cannot be used in the first two positions or last position of Usernames. Password must contain each of the following 1 Upper & Lower case letter, 1 number & 1 symbol (ex. !@ #$ % &*) Be aware that Passwords are Case Sensitive. Network Equipment and Services Equipment 5-Port Ethernet Switch ........................ $45.00/ea 8-Port Ethernet Switch ........................ $65.00/ea CAT-5e Wire ......................................... $ 0.50/ft Networking Labor (1/2hr increments) ........... $65.00/hr Custom Solutions are available for your home. Please ask for details! Services Wireless Router Configuration .............$16.25 Additional E-Mail-Boxes .......................$ 2.00/mo ($2.00 Set-up Fee per E-Mail-Box) Static IP Address ..................................$ 5.00/mo Website Hosting....................................$19.95/mo Secured Server .....................................$ 5.00/mo ($30.00 Set-up Fee) Custom Router Configuration..............$65.00/hr House Visits (1/2hr increments) ....................$65.00/hr Notices Attention: All bills are rendered the first of each month and are due upon receipt. Payment within ten days is requested. Payments are due by the 23rd of each month; after that date, unpaid accounts are considered delinquent. Please bring or send the payment page from your bill when payment is made. All bills stand correct and will not be adjusted after the tenth of the month of the bill. Applicants are subject to approval and will be notified if a deposit is required. All New Subscribers: Per CC Docket 91-115, we are required to notify you of the following FCC regulations. Whenever you accept a third party number or collect call, we are required to release your billing name and address (BNA) information to the Interexchange Carrier (IXC) that handles the call. This information is necessary to enable the IXC to bill you for the call, should it not be billed on your MIDTEL bill. According to the FCC regulations, IXC's can use your BNA information for several reasons other than billing, which include verification for pre-subscription and new address purposes, fraud prevention, and similar non-marketing purposes. NONPUBLISHED Customers ONLY: As a non-published customer, your number does not appear in our telephone directory, in directory assistance, etc., nor do we release it if we receive a request. Regarding the above FCC regulations, you have a choice as to whether you want to have your BNA released in the above described circumstances. However, should you choose not to allow BNA release, you may not be able to make third party number calls or receive collect calls on your telephone number. Initial below if you wish to restrict BNA release. Otherwise, we are required by the FCC to release your BNA information to requesting IXC's. AS A NONPUBLISHED CUSTOMER, I hereby request that, under no circumstances, is my Billing Name and Address (BNA) to be released. I understand that I may not be able to make third party number calls, and may not be able to receive collect calls on my telephone number. Do Not allow my BNA to be released _______ (initial) NOTICE: For the Protection of YOUR Privacy YOU MUST PROVIDE US WITH THE CURRENT BILL STATEMENT If you do not have your bill statement with you we CANNOT share any customer information NOT EVEN THE AMOUNT OF THE BILL WITHOUT YOUR IDENTITY BEING AUTHENTICATED. You then will be asked to provide us with a valid Government issued photo ID that matches the name on the account. If you do not have this and have misplaced your bill statement we will be happy to mail you another copy to the billing address we have or call you at the number of record. We will be glad to accept any payment towards your account in any amount you choose but we CANNOT share any account information without proper ID or the bill statement. We apologize for any inconvenience this may cause. Federal CPNI Laws dictates these safeguards to protect your privacy and the information contained on your monthly bill. Payment Options Online Pay MIDTEL offers an Online way to pay your monthly bill(s). MIDTEL Online Pay allows you to pay your monthly bills from your credit card (MC, Visa, Discover or AMEX), checking, or savings account. Processing can take two (2) to three (3) business days for the payment to post. Please keep this in mind when setting your payment frequency. A MIDTEL CSR can assist you! E-Z Pay Options MIDTEL offers a way of making it easy to pay your monthly bill(s). MIDTEL E-Z Pay Program allows you to pay your monthly bills from your credit card (MC, Visa, Discover or AMEX), checking, or savings account. Your payments will be automatically deducted on the 10th of the month, or the next business day thereafter if the 10th falls on a weekend or holiday. * Separate form required, please ask. Monthly Bill Still prefer to pay your monthly bills manually? MIDTEL will mail your bill to the address you provide. Payments are due by the 23rd of the month by either mailing a check, paying online, paying over the phone, or coming to our office. We also have an "afterhours" Drop Box located outside. We are open 8:00am to 5:00pm Monday to Friday, except Wednesday, which our hours are 8:30am to 5:00pm. Pre-Payment Information Pre-payment options are available, and may be REQUIRED. The pre-payment can cover installation, monthly fees, and add-on services. NOTE: This is for ONE TIME payment only, this information will not be used for any on-going monthly charges. I would like to Pre-Pay Credit or Debit Card Cash Check Visa MasterCard American Express Discover Card #: _____________________________________________________________ Expiration (mm/yyyy): ________/_____________ Sec. Code: __________ Pre-Paid Amount $______________ Special Instructions: By signing this form I agree to all policies set forth by MIDTEL. I give permission to install High Speed Internet via Fiber To The Home (FTTH) and charge me any applicable installation fees. I understand that the installation fee is refundable only if I am unable to receive a FTTH signal. Any prepayments for installation are not refundable if I choose to cancel the service or installation after work has been completed. I understand there may be a one-time charge if my inside wire, Ethernet wire, or coaxial wire is moved to a new location for installation. Bandwidth Caps may apply due to excessive abuse. Please see the MIDTEL Acceptable Use Policy and Terms and Conditions on our website, www.MIDTEL.com. Signature: _____________________________________________ Date: _____________________ 103 Cliff Street, PO Box 191, Middleburgh, NY 12122 | Email: sales@midtel.com | 518.827.5211 | Fax: 518.827.7600Acrobat Distiller 20.0 (Windows)