Choctaw Telephone Company New Service Application

Date:_____________Installation Date:_________________Contact Number:___________

Applicant’s Name:_________________________________Spouse:____________________

Service Address:___________________________________________________________

Billing Address:____________________________________________________________

Social Security Number:______________________Published in Directory: Yes____No____

Published Name:____________________________________Add List: Yes____No____

Add List Name:(.40 per month)_________________________Residence:___Business____
Local Service (Dial Tone) $9.90 per month Add $1.00 for Non Pub Number
The Install Charge for new servcie is $17.50. Also applies for changing to or from MCA service.
Metropolitan Calling Area MCA Residence: $11.45_____ Business $21.75_____
Repair Plus: $1.25 per month (Read page 3 of the directory for terms and conditions)Yes__No__
Do you want this line to have the following blocks (N/C): 900 ___Collect ___ Bill 3rd Number___

All Calling Options have Install Charge of: $5.00 for the 1st and $1.00 for each additional option
Per month charges for Calling Features Options 1:
1 feature $2.00 2 feature $3.75 3 feature $4.50 4 feature $5.00

Call Wait

Call Forward

3-Way Call

Cancel Call Wait

Call Forward Busy

Toll Block

Coded Ring

Call Forward No Answer

Home Intercom
Calling Features Options 2:
All Option 2 Calling Features are $3.50 each per month

Automatic Call Return

Selective Call Acceptance

Selective Call Rejection

Automatic Redial

Selective Call Forwarding

Anonymous Call Rejection

Distinctive Ring

Selective Toll Block ($3.00)
Call Features Options 3
All Option 3 Calling Features are $5.00 each per month

Caller ID

Number Referral

Line Hunting (2 or more lines)
The undersigned makes application for the above service and agrees to pay established rates for each service. In making the application the undersigned agrees to the rules and regulations of Choctaw Telephone Company as set fourth in the exchange tariff and in all changes in the rules, regulations, tariffs, or rates for the service furnished under this application. I understand if additional lines are added in the future, if one line is disconnected for nonpayment purposes the other line may also be suspended. I understand that the undersigned is responsible for any and all long distance charges made from, or charged to this account. All Charges do not include taxes.

Applicants Signature:_________________________Order taken by:________________________