Residential Service Application 1Residential Applicant Info2Location of Service3Payment Options4Residential Services5Agreements, Signature X/TwitterThis field is for validation purposes and should be left unchanged.Residential Applicant InfoApplicant Name(Required) First Middle Last Birthdate (MM/DD/YYYY)(Required) Month Day Year Social Security Number(Required)Mailing Address(Required) Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Authorized Contact MethodEmail Address(Required)Authorized Contact Method Work PhoneGDPR (General Data Protection Regulation)(Required)By agreeing you authorize RTC Networks to review your credit history and acknowledge that RTC may use your customer information for their collection process. You understand their use of your information will comply with the Fair Credit Reporting Act. Should you choose not to agree, please note that that a deposit will be required. Agree - Credit check will be run. Disagree - Deposit required. Is this a joint account? Yes No This field is hidden when viewing the formJoint AccountJoint Applicant Name First Middle Last Birthdate (MM/DD/YYYY)(Required) Month Day Year Social Security Number(Required)Mailing Address(Required) Mailing Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell Phone(Required)Work PhoneEmail Address(Required) This field is hidden when viewing the formSection BreakCPNI Security Password(Required)This is a password of your choosing that will be required to verify your account when calling in to RTC Networks.Security Questions(Required)Please complete as many of the following questions below as you can. When you call RTC Networks without your password, you will have to correctly answer two questions in order to access your account information.What is your favorite book?What is the color of your first car?What is your favorite food?What is the name of your favorite pet?What is your favorite song?What is your favorite vacation spot? Add RemoveWould you like other admins on the account? Yes No List Authorized Admins(Required)Authorized individuals who are allowed to access or make changes to the account.NameEmailPhone Add Remove Location of ServiceCity(Required)County911 Physical Address(Required)Is your location within city limits? Yes No TownshipSectionRangeLatitudeLongitudeDo you: Rent Own Name on Lease(Required)Previous OccupantHave you had RTC service before? Yes No Previous #/name on account(Required) Payment OptionsWould you like to sign up for SmartHub (online payment portal)?(Required) Yes No Email Address(Required)SmartHub password link will be sent to this email address. Would you like to go paperless?(Required) Yes No Would you like to be on an automatic payment plan?(Required) Yes No Type of account for automatic payments?(Required) Checking Savings Upload Voided Check(Required)Must attach a voided check to complete.Max. file size: 100 MB. Upload Deposit Slip(Required)Must attach a deposit slip to complete.Max. file size: 100 MB. Name(Required) First Last Cell Phone(Required)Name of Financial Institution(Required)Routing Number(Required)Bank Account Number(Required)Applicant Printed Name (must match name on bank account)(Required)By entering your name, you are effectively providing your signature and authorizing the financial institution to pay your monthly RTC Networks service bill by charging your account for each payment. You agree that each payment shall be the same as if it were an instrument personally signed by you. This authority is in effect until revoked by you in writing or by email, no less than 3 business days prior to the date of the recurring payment. In addition, you have the right to stop payment of a charge by timely notification to RTC Networks no less than 3 business days prior to the date of the recurring payment. If you close or change your account, you will notify RTC Networks. You understand, however, that both the financial institution and RTC Networks reserve the right to terminate this payment plan, or your participation therein. *About 2 months after you sign up, you’ll receive a notice on your RTC Networks statement that says, “Pay by Bank- Do Not Pay.” Until you see that statement, continue to pay your bill using your current method. Payments will be deducted the 15th of each month or the first business day thereafter.Would you like to enable pay by phone?(Required)RTC Secure Payment #: (855) 940-3817. Yes No Secure Pay Pin(Required)Pin required when you call RTC Secure Payment #. MUST BE 4 DIGITS (please do not use 0 as the first digit).Please enter a number from 0000 to 9999.Are you sales tax exempt?You must live on Tribal Lands. Yes No Enrollment #(Required)Do you qualify for telephone or Internet assistance?Learn more about assistance programs. Yes No If yes, do you live on Tribal Lands? Yes No Residential ServicesNote: myRTCtv requires RTC Networks internet serviceSelect Services(Required) Broadband Internet Phone myRTCtv You must also select Broadband Internet to see TV packages/options. Internet service from RTC Networks is required for TV service.BroadbandBroadband Internet (Includes Unlimited Data Usage, Total Experience Wi-Fi , myRTCnet app)Choose a package. $30 activation (Speeds are up to the listed speed and may be limited in some areas.) *Pricing does not include fees and taxes. View Residential Broadband Facts Labels (PDF) The Connected Lifestyle Plan - 500 Mbps x 500 Mbps - $80 per month The Power User Plan - 1 Gig x 1 Gig (1,000 Mbps) - $105 per month The Trail Blazer Plan - 5 Gig x 5 Gig (5,000 Mbps) - $250 per month Wi-Fi Password(Required)Minimum of 8 characters, 1 number and 1 capital letter.PhoneBasic Residential PhoneApproximately $33 per month + $30 activation. Unlimited Long Distance Included (does not include international calling) Yes No This field is hidden when viewing the formSection BreakPhone FeaturesAdditional calling features available Call Waiting - $1 per month Three-way Calling - $1 per month Caller ID - $4 per month Call Forwarding - $1 per month Voicemail (See Options) Voicemail Options Gold ($5 per month) Silver ($4 per month) Bronze ($3 per month) Long Distance NDLD Flat Rate (14¢ per minute in-state, 8¢ minute state-to state) NDLD Nationwide (10¢ per minute, $3.95 per month) No Long Distance Would you like a PIC freeze? Yes No Would you like your phone # listed in the directory? Yes No List as: PO Box Physical Address Both Would you like an additional listing?$1 per month per additional listing Yes No List as:If no: Non-listed 50¢ per month (# available on caller ID display & thru information) Non-published $1 per month (# not available anywhere) International call blocking is automatically added at no charge. If you do not want the block check here. Remove Block myRTCtvmyRTCtvChoose a package. Lite - $58.59 per month Expanded - $131.81 per month Platinum - $143.59 per month Email Address for myRTCtv(Required)Email address to use for myRTCtv login If you sign up for the Lite, Expanded, or Platinum package, you can also sign up for any or all of the following packages.Premium PackagesPremium channels included in Absolutely Everything package HBO - $18.95 per month Cinemax - $15.95 per month Starz & Encoure - $15.95 per month NFL Red Zone - $55.00 per NFL Season Paramount+ with Showtime - $15.95 per month StreamsAll packages include 6 free streams, $2.50 per month for each for additional. 6 included streams - Free Additional stream 1 - $2.50 per month Additional stream 2 - $2.50 per month Additional stream 3 - $2.50 per month Additional stream 4 - $2.50 per month Additional stream 5 - $2.50 per month DVR HoursAll packages include 100 DVR hours, $5 per month for each for additional / Absolutely Everything package includes 300 DVR hours 100 DVR hours - Free Additional 100 DVR hours (total 200) - $5 per month Additional 200 DVR hours (total 300) - $10 per month Set-top boxLease Lease - $5 per month each Want additional boxes?Enter #Installation RTC Networks Assisted Installation - $50 Self Installation - Free Comments Agreements & SignatureHigh Speed Broadband Internet Agreement(Required)By signing this application, Customer agrees to the following. High Speed Internet service activation includes a single home run wire to a designated point for handoff to a residential gateway and RTC Networks' Technicians will verify internet connectivity. Any additional work done at the customer's request (including, but not limited to, moving existing jacks or installing new jacks) will be billed at RTC Networks prevailing hourly rate plus materials.RTC Networks offers 1 residential gateway for lease as part of the package. Residential gateways, power supplies, and cords remain the property of RTC Networks, and in some cases, may need to be returned when service is disconnected. Equipment that is not returned within 5 days after disconnection will be billed to the Customer at reasonable retail rates.RTC Networks provides this service for the purpose of direct access to the Internet. This is not a wholesale service therefore it cannot be resold by the customer. Please read RTC Networks' Acceptable Use Policy. Violation of the policy may jeopardize your service. I have read and understand the above information and authorize RTC Networks to install high speed internet service. I am at least 18 years of age and the name on the account where the service will be installed matches the name above. Agreement is nontransferable.VoIP Acknowledgement(Required)If you selected VoIP service above, you acknowledge and understand that VoIP Service is different in a number of important ways from traditional phone service, and you agree to inform any household residents, guests and other third persons who may be present at the physical location where you utilize the Service of the differences and limitations of the Service. Such differences include but are not limited to: The 911 service may not function in the event of power failure, or outage of, or termination of service with or by your Internet/service provider and calls from your location to any Enhanced 911 emergency center will report the physical address you provided when the service was initiated. I have read the text above.Operation Round Up(Required)All RTC Networks customers are automatically enrolled in our Operation Round Up program, a community-service fundraising initiative. Under this program, your bill will be rounded up to the nearest dollar, and 100% of the additional funds will be awarded to qualifying local community projects based on applications from our members. If you prefer not to participate, please contact us and we will remove you from the program. I have read and understand the text above.Equipment Agreement(Required)Delivery, Use, Care, Replacement Services, Right of Entry By signing this application, you agree that any equipment delivered and installed at your address as reflected in our business records, is for personal use at said address. You agree not to remove it from the address except to return it to us. You agree to take reasonable care of the equipment and agree not to open the equipment (except change batteries in the remote control), take apart, or to alter it in any way. You are responsible for all damage to the equipment, beyond reasonable wear from normal use, which occurs before you return or surrender it to us. The equipment must be returned in fully usable condition. Except for damage caused by misuse or abuse, if you notify us of equipment failure, we will repair it or exchange it for properly functioning equipment. You agree to allow us to enter your installation address, at any reasonable time, to inspect, repair, replace, or remove the equipment. Payment for use of service and failure to comply with agreement Your use of the equipment and services you receive are subject to the various policies of RTC. Such policies and practices are subject to change. Monthly fees for use of the equipment are billed in advance. If you fail to comply with your commitments contained herein, or with any term of the agreement under which you are receiving services from us, you understand and agree we may do any combination of one or more of the following: 1.) terminate your right to use of the equipment; 2.) terminate your right to receive services from us; 3.) recover the equipment; 4.) bring legal or other action for return of the equipment and any amounts due to us hereunder, together with liquidated damages for failure to return the equipment as required herein. If you choose to stop using the equipment: You may terminate your use of the equipment by contacting customer service. When you do so, or if we terminate your right to use the equipment as described above, we will ask you to return the equipment. All rental payments and additional charges will be due to us at this time. You agree to cooperate and make yourself available to return the equipment to us. Equipment not returned upon disconnect is billable. Liquidated damages for failure to return equipment If you fail to timely return the equipment to us in accordance with your commitment herein, you understand and agree that the costs and damages we will incur are not readily ascertainable and are difficult to predict or calculate at the time. You agree that a reasonable estimate of our damages is the replacement cost for the equipment and power cord(s), plus the costs associated with our attempts to recover the equipment from you. Again, when you are required to return the equipment to us, we appreciate in advance your cooperation in making sure the equipment is promptly returned. *All materials and labor inside premise will be billable above and beyond the activation charge. Note: An incomplete application may delay installation of services. I agree to the equipment agreementService Application Consent(Required) I (We) hereby apply for phone/internet/tv service from RTC, with the understanding that I (We) am (are) fully responsible for payment of the account. I (We) further agree that RTC can apply any accumulated capital credits to the account if the account becomes delinquent. Furthermore, by signing this service agreement, I(We) hereby agree to abide by the rules, regulations and by-laws of the cooperative, which can be found at www.RTC.coop, or by calling the RTC office, and, if applicable, the equipment and internet agreements outlined above. By entering your initials on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.Applicant Printed NameUpload ID(Required)Please submit a copy or photo of a valid ID. Drop files here or Select files Max. file size: 100 MB, Max. files: 1. Joint Applicant Printed NameJoint Applicant Upload ID(Required)Please submit a copy or photo of a valid ID. Drop files here or Select files Max. file size: 100 MB, Max. files: 1. Statement of Non-Discrimination This institution is an equal opportunity provider and employer. Payment Options Brochure (PDF) Power Backup Disclosure (PDF)Additional Comments / Information Having trouble completing the online application? A paper application (PDF) is also available.
