Telephone Application

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=85 BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="18700660egerdp.jpg"> <div> </div> </td> </tr><tr> <td valign="top" width=150 BGCOLOR="#333366" TEXT="#080000" background="03fcac00dkcfsz.png"> <div> <A HREF="index.htm" TARGET="_top" TITLE="New Hope Telephone Company"><U><IMG SRC="15c821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="about_us.htm" TARGET="_top" TITLE="About Us"><U><IMG SRC="151821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="customer_service.htm" TARGET="_top" TITLE="Customer Service"><U><IMG SRC="152821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="products_and_services.htm" TARGET="_top" TITLE="Products and Services"><U><IMG SRC="153821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <div> <A HREF="internet.htm" TARGET="_top" TITLE="Internet"><U><B><IMG SRC="155821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <bR> <bR> <div> <B><U>Telephone</U></B></div> <div> <A HREF="local_calling.htm" TARGET="_top" TITLE="Local Calling Area"><U><B><IMG SRC="165821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="long_distance.htm" TARGET="_top" TITLE="Long Distance"><U><B><IMG SRC="166821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="features.htm" TARGET="_top" TITLE="Features"><U><B><IMG SRC="167821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> <div> <A HREF="telephone_support.htm" TARGET="_top" TITLE="Telephone Support"><U><B><IMG SRC="168821a0.jpg" border=0 width="130" height="26" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A></div> </td> <td valign="top" height=395 BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="0eac8c83.jpg"> <div> <FONT SIZE="1" COLOR="#0000BF" FACE="Arial" >  </FONT>Applying for Telephone Service</div> <html> <head> <title>Application For Telephone Service</title> </head> <bR> <body BGCOLOR="CFCFCF" TEXT="000000"> <bR> Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if your are not using a forms-capable browser) you may email your response to: <A HREF="mailto:questions@newhopetel.com" TARGET="_top" TITLE="mailto:questions@newhopetel.com"><U><I>questions@newhopetel.com</I></U></A> <form name="WF_3" method="POST" action="http://internet.citizens.coop/scripts/nbformmail.pl" onSubmit="return checkdata()">  <input type=hidden name="recipient" value="!i*n#####fo###########@newhope#####tel.############################c##################om,t######imh****arris!@newho######petel.co#######################m"> <input type=hidden name="subject" value="NHTC Telephone Application"> <input type=hidden name="redirect" value="http://www.newhopetel.net/thank_you_for_your_application.htm"> <bR> <SCRIPT LANGUAGE="JavaScript">  <bR> </SCRIPT> <bR> <p><PRE>Last Name: <INPUT TYPE="text" NAME="Last_Name" SIZE=35 VALUE=""></PRE> <p><PRE>First Name: <INPUT TYPE="text" NAME="First_Name" SIZE=35 VALUE=""></PRE> <p><i>(Street Address is for the location that you are applying for service)</i> <p><PRE>Street Address Line 1: <INPUT TYPE="text" NAME="Street_Address_Line_1" SIZE=35 VALUE=""></PRE> <p><PRE>Street Address Line 2: <INPUT TYPE="text" NAME="Street_Address_Line_2" SIZE=35 VALUE=""></PRE> <p><PRE>City: <INPUT TYPE="text" NAME="City" SIZE=35 VALUE=""></PRE> <p><PRE>Zip Code: <INPUT TYPE="text" NAME="Zip_Code" SIZE=10 VALUE=""></PRE> <p><PRE>Mailing Address Line 1: <INPUT TYPE="text" NAME="Mailing_Address_Line_1" SIZE=35 VALUE=""></PRE> <p><PRE>Mailing Address Line 2: <INPUT TYPE="text" NAME="Mailing_Address_Line_2" SIZE=35 VALUE=""></PRE> <p><PRE>City (Mailing Address): <INPUT TYPE="text" NAME="City_(Mailing_Address)" SIZE=35 VALUE=""></PRE> <p><PRE>State: <INPUT TYPE="text" NAME="State" SIZE=2 VALUE="VA"></PRE> <p><PRE>Zip Code (Mailing Address): <INPUT TYPE="text" NAME="Zip_Code_(Mailing_Address)" SIZE=10 VALUE=""></PRE> <p><PRE>Current Phone Number: <INPUT TYPE="text" NAME="Current_Phone_Number" SIZE=12 VALUE=""></PRE> <p><PRE>Contact Phone Number: <INPUT TYPE="text" NAME="Contact_Phone_Number" SIZE=12 VALUE=""></PRE> <p><i>A Customer Service Representative will need to call you. What is your preferred time to receive this call (must be 8:00 am - 12 noon or 1:00 pm - 4:30 pm).</i> <p><PRE WIDTH=30>Time to Call: <INPUT TYPE="text" NAME="Time_to_Call" SIZE=10 VALUE=""></PRE> <p><PRE>Social Security Number: <INPUT TYPE="text" NAME="Social_Security_Number" SIZE=11 VALUE=""></PRE> <p><PRE>Drivers License Number: <INPUT TYPE="text" NAME="Drivers_License_Number" SIZE=15 VALUE=""></PRE> <p><PRE>Birth (Month/Day/Year): <INPUT TYPE="text" NAME="Birth_Month" SIZE=12 VALUE="">  <INPUT TYPE="text" NAME="Birth_Day" SIZE=2 VALUE="">  <INPUT TYPE="text" NAME="Birth_Year" SIZE=4 VALUE=""></PRE> <p><PRE>Employer Name: <INPUT TYPE="text" NAME="Employer_Name" SIZE=35 VALUE=""></PRE> <p><PRE>Employer Address Line 1: <INPUT TYPE="text" NAME="Employer_Address_Line_1" SIZE=35 VALUE=""></PRE> <p><PRE>Employer Address Line 2: <INPUT TYPE="text" NAME="Employer_Address_Line_2" SIZE=35 VALUE=""></PRE> <p><PRE>Employer City: <INPUT TYPE="text" NAME="Employer_City" SIZE=35 VALUE=""></PRE> <p><PRE>Employer State: <INPUT TYPE="text" NAME="Employer_State" SIZE=2 VALUE="VA"></PRE> <p><PRE>Employer Zip Code: <INPUT TYPE="text" NAME="Employer_Zip_Code" SIZE=10 VALUE=""></PRE> <p><PRE>Employer Phone Number: <INPUT TYPE="text" NAME="Employer_Phone_Number" SIZE=12 VALUE=""></PRE> <p><PRE>Employment Years: <INPUT TYPE="text" NAME="Employment_Years" SIZE=2 VALUE=""></PRE> <p><PRE>Employment Months: <INPUT TYPE="text" NAME="Employment_Months" SIZE=2 VALUE=""></PRE> <p>What type of service are you applying for?<br> <p><SELECT NAME="Type_Of_Service"> <OPTION SELECTED> Residential <OPTION> Business </SELECT> <p>Do you want your name and number published in the directory?<br> <p><SELECT NAME="Directory_Published"> <OPTION SELECTED> Yes <OPTION> No </SELECT> <p>If yes, enter how you want the listing to appear.<br> <p><PRE>Directory Name: <INPUT TYPE="text" NAME="Directory_Name" SIZE=35 VALUE=""></PRE> <p><PRE>Directory Address: <INPUT TYPE="text" NAME="Directory_Address" SIZE=35 VALUE=""></PRE> <p>Do you want your number listed in directory assistance?<br> <p><SELECT NAME="Directory_Listed"> <OPTION SELECTED> Yes <OPTION> No </SELECT> <p>Select calling features,other features may be available, ask Customer Service Representative for a complete listing<br> <bR> <div> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Automatic Callback">Automatic Callback</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Automatic Recall">Automatic Recall</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Call Forward Busy">Call Forward Busy</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Call Forward No Answer">Call Forward No Answer</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Call Forward All">Call Forward All</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Call Waiting">Call Waiting</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Caller ID">Caller ID</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Three Way Calling">Three Way Calling</div> </tD> <tD VALIGN=TOP><NOBR><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Selective Call Acceptance">Selective Call Acceptance</div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 ><NOBR><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Selective Call Forwarding">Selective Call Forwarding</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Selective Call Rejection">Selective Call Rejection</div> </tD> <tD VALIGN=TOP WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Toll Control with PIN">Toll Control with PIN</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 16 WIDTH="200"><div> <INPUT TYPE="checkbox" NAME="Features" VALUE="Teen Service">Teen Service</div> </tD> <tD ALIGN=RIGHT VALIGN=BOTTOM><NOBR><div> <FONT SIZE=2><I>(Multiple items may be chosen)</I></div> </NOBR></tD> <FONT SIZE=3> <tD VALIGN=TOP WIDTH="200"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="16" ALIGN="bottom" WIDTH="200" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> </td> </tr></table></body> <p><br> <p>Are you interested in New Hope Telephone Internet Service?<br> <p><SELECT NAME="NHT_Internet_Service"> <OPTION SELECTED> Yes <OPTION> No </SELECT> <br> <br> <p>Please be aware that payments are due by the 24th of each month. Payments received after the 24th will result in a 1.5% late fee per month (which is an annual percentage rate of 18%).<br> <p>In addition, payments not received within 45 days of bill date will result in disconnection of your service. If your service is disconnected, you will be responsible to pay the amount owed plus a $25.00 reconnection fee and a $75.00 deposit.<br> <p>If payment has not been made within 15 days of disconnection, the account will be considered delinquent. In the event this account becomes delinquent, the customer shall pay all of the attorney fees and costs associated with collection of the account plus all attendant collection fees whether litigation is initiated or not.<br> <p>Notes:<br><TEXTAREA name="Notes" rows=10 cols=50></TEXTAREA><p> <p><PRE>Date: <INPUT TYPE="text" NAME="Date" SIZE=15 VALUE=""></PRE> <p>By clicking the Submit button, you are indicating that you have read, understood and agreed to the information provided.<br> <p> <bR> <p><INPUT TYPE="hidden" NAME="WebFormID" VALUE="3"> <p><INPUT TYPE="submit" VALUE="Submit"> <INPUT TYPE="reset" VALUE="Reset"> </FORM> <p> <hr><FONT SIZE=-1>NEW HOPE TELEPHONE COOPERATIVE DOES NOT DISCRIMINATE AGAINST APPLICANTS ON THE BASIS OF SEX, MARITAL STATUS, AGE (EXCEPT UNDER AGE 18), RACE, NATIONAL, ORIGIN OR RELIGION. (THE FEDERAL AGENCY WHICH ADMINISTERS COMPLIANCE WITH THIS LAW IS THE EQUAL CREDIT OPPORTUNITY, FEDERAL TRADE COMMISSION, WASHINGTON, D.C. 20580) </FONT> <br> <hr> <A HREF="mailto:questions@newhopetel.com" TARGET="_top" TITLE="mailto:questions@newhopetel.com"><U><I>questions@newhopetel.com</I></U></A><br> <FONT SIZE=-1>©2004 New Hope Telephone, All Rights Reserved<br></FONT> </body> </html> <bR> </td> </tr></table></body>