West Wisconsin Logo West Wisconsin Telcom Cooperative, Inc.

Membership Application

PO Box 115
Downsville, WI 54735
Phone: 715-664-8311
Fax:715-664-9982
Office Use Only

Date:_______________

Account: ____________

Phone No: ___________
Customer Information
Knowingly providing incorrect information can result in immediate termination of service.		 
Your Name           
Company Name        
Service Address     
City                
State                ZIP
Social Security No  
Driver's License No 
Date you need Service      
Will jacks and/or wiring be needed at this location?
(Labor rates will apply):   Yes No
Residence Is:

Please list last person at this location or
nearest neighbor who has telephone service.
Full Name   
Telephone # 



Current Employer's Name:


Employer's Telephone #:
Billing Information (if different from above)
 
	Name             

	Mailing Address  

	City             

	State            

	ZIP              
Would you like one of these Billing Services:
Customer History
 
Previous Address    
City                
State                ZIP
Telephone #         
Previous Company    
Directory Information
Published
Unlisted
Unlisted/Unpublished
Main Phone Line: Do Not Need
This Line		 YES YES YES
2nd Phone Line: Do Not Need This Line YES YES YES
Directory Listing (as it should appear in the directory)
Main Directory Listing
Name:     

Address:  
Additional Directory Listing
Name:     

Address:  
 Yes - Omit Address from Directory.
Telephone Service Details
 
Date to begin service               
Daytime Phone Number                
Relative Name                       
Relative's Telephone #              
Will someone be at residence on this date:
Yes    No
Package Plans
Basic Connection
Includes Phone Line & Unlimited Calling
Clear Choice
Basic Connection, 1 Calling Feature & 1 Specialty Feature
Total Choice
Basic Connection, 2 Calling Features & 2 Specialty Features
Main Phone Line Do Not Need
This Line		 YES YES YES
2nd Phone Line Do Not Need
This Line		 YES YES YES
Calling Features
Available Calling Features
Available Specialty Features
Main Line
2nd Line
Main Line
2nd Line
Call Waiting
Call Transfer
Cancel Call Waiting
Caller ID Number
CallerID/Call Waiting
Caller ID Name/Number
Call Forwarding
Automatic Recall
Call Forward Busy
Automatic Callback
Call Forward No Answer
Select Call Accept
Call Forward, Remote Answer
Select Call Forward
Speed Call 30
Select Call Reject
Speed Call 8
Select Distinct Ring
Teen Line
Voice Mail
Three Way Calling
Wire Maintenance     Line 1      Line 2
Long Distance Options
Please contact the long distance carrier you have chosen to set up your new billing account. You must choose a Long Distance Carrier or you will not be able to place long distance calls.

Interlata Carrier:      Intralata Carrier: 
Toll Blocking (Free of Charge):
900 Numbers   Collect Calls   Third Number
Long Distance Freeze (Free of Charge)* Yes   No:
* Your long distance can not be changed unless you give handwritten permission to our office.
Please Read the Following and Sign at the Bottom
The undersigned, hereinafter called the "Applicant", hereby applies for membership in West Wisconsin Telcom Cooperative, Inc., a corporation duly organized and existing under and by virtue of the laws of the State of Wisconsin, hereinafter called the "Cooperative", for the purpose of having furnished to said "Applicant" Telecommunication services upon the following terms and conditions:

The "Applicant" will take from the "Cooperative" Telecommunication services when available and will pay monthly rentals to the "Cooperative" in accordance with the rate schedules and rules and regulations established by the "Cooperative" in accordance with the directives of the United States of America and the State of Wisconsin and their regulatory bodies.

The "Applicant" hereby grants to the "Cooperative", a right-of-way easement to construct, operate and maintain a Telecommunications line or system on "Applicants" premises and in or upon all streets, roads or highways abutting said premises, and also such service lines that are necessary, and also the right to cut or trim trees and to bury cable necessary to the efficient operation of said system. The "Applicant" will comply with and be bound by the provisions of the by-laws, rules and regulations of this Cooperative and such amendments as may from time to time be adopted. The "Cooperative" reserves the right to check credit references or credit agencies for reports.
Signature of Applicant

Customer Signature ____________________________________________   Date_______

Customer Signature ____________________________________________   Date_______

(Husband & Wife should both sign if joint application)

Print out this form and mail along with a $50 advance payment. Advance payment will be applied to your first bill.

West Wisconsin Telcom
PO Box 115
Downsville, Wisconsin 54735

Phone (715)664-8311 -- Fax (715) 664-9982