Please utilize this form to sign up for service. Our customer care consultants will contact you regarding the application process once you have submitted the form. I am applying for:* Telephone Internet Television Applicant desires service as:* Residential Business Name* First Last Social Security Number*Spouse's Name First Last Spouse's Social Security NumberAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Contact Telephone Number*Have you had telecommunication services before?* Yes No Previous telecommunications companyPrevious company telephone numberYour current employer*Work telephone numberList names of all members of the household over 18 years old:*Name of party who lived at location last, if known:How did you hear of RC's Services?*NewspaperRadioTelevisionFriends & FamilyName of person that referred you to RC (if applicable): First Last Would you like to add the optional maintenance plan for $2.00 per month?* Yes No Do you want your name published in RC's telephone directory Yes No If no, do you want it Unlisted or Non-published? Unlisted - $2.00 per month Non-published - $3.00 per month Your name as you'd like it to appear in the directory (ie. John & Jane Smith) First Last Which address(es) would you like listed in the directory?* Physical Mailing None Additional directory listing (if any, $1.50 per month) First Last Telephone FeaturesI would like the following telephone features: (Call waiting, Voicemail and Calling name & number are included in bundles) Call Waiting - $1.75 per month Distinctive Ring - $2.00 per month Calling Name & Number - $5.95 per month 3rd Party Blocking - FREE Toll Denial - $3.00 per month Call Blocking - FREE Find Me - $3.50 per month Call Forward - $1.75 per month 3-Way Calling - $1.75 per month International Blocking - FREE Collect Blocking - FREE 900 Blocking - FREE Telemarketer Call Screening - $1.50 per month Long Distance:Regulations now require you to select a long distance company to provide your 1+ dialed InterLATA (out-of-state) and IntraLATA (in-state) long distance service for calls outside your local telephone company calling region. Please contact one of the long distance carriers on the sheet of carriers, ask them about their calling plans, and then select one of the equal access long distance companies. NOTE: These long distance carriers are listed in no particular order. Please indicate your choice of long distance carriers below. Your choice below will be applied to both Intra and Inter LATA calls.RC Long DistanceAT&TExcelMCICenturyLinkVerizonLevel 3 CommunicationsRC Long Distance Minutes:You can add a bucket of minutes to your telephone service. Overage is billed at 10 cents per minute on the 90 and 200 minute plans. 90 Minutes per month - $8.00 200 Minutes per month - $15.00 Real Deal - 14 cents per minute within the US I'd like to register for a tnics email address (optional) Yes No Utilize my current email address only Yes No Current email address* I would like my wireless network (SSID) name to be:*I would like my wireless network password to be: (password must be at least 8 characters with at least one capital letter and one number)*I would like to add the following additional services to my internet account Secure IT Virus Protection - $4.95 per month File Hopper - 5GB storage - $3.95 per month File Hopper - 50GB storage - $6.95 per month File Hopper - 250GB storage - $14.95 per month Password Genie - $1.75 per month I would like to add digital video to my account with the following package (RCTv service not available in all areas) Local Package - $29.95 per month Basic Package (includes local) - $75.00 per month Expanded package - (must have basic) - $14.95 per month Number of TV's in the household:*Number of set top boxes requested (one standard set top included in monthly package, $4.95 per month for each additional standard set top box)*Please add the following premium channels to my package (must have basic package to receive premium channels): HBO - 5 Channels - $18.95 per month Cinemax - 4 Channels - $14.95 per month Showtime - 9 Channels - $16.95 per month Starz! & Encore - 11 Channels - $14.95 per month Playboy - 1 Channel - $12.95 per month BU - 1 Channel - $12.95 per month I am interested in adding the following options to my video service HD Package - not available in all areas - $9.95 per month DVR Set Top Box - not available in all areas - $7.95 per month HD DVR Suite - not available in all areas - $11.95 per month The FCC has implemented rules to protect the privacy of information contained in your account. The rules allow us to discuss account information only with the person(s) listed on the account. Also, RC must be able to authenticate that person and will do that by asking a specific question to which you have previously provided the answer. RC has always treated your account information with confidentiality. In order to ensure your information is protected, please provide an answer to the question "In what city were you born?"* City State / Province / Region The undersigned (hereinafter called the applicant) hereby applies for service in the RC Technologies., New Effington, South Dakota (hereinafter called the company). applicant agrees upon the following terms and conditions: 1. The Applicant will be charged, as appropriate, non-refundable service order and installation fees at the company’s tariffed rates and price list. The applicant may also be required to make a deposit. 2. The applicant must be at least 18 years of age. 3. The applicant will receive service from the company at his/her place of residence and/or business, and will pay therefore monthly rates to be determined from time to time in accordance with the tariffs and policies of the company. The applicant will also pay to the company all just and proper charges accruing to long distance carriers who employ the services of the company for billing and collection purposes if applicable. 4. The applicant will grant to the company, as appropriate, a right-of-way easement to construct, reconstruct, operate and maintain telecommunications and information services, cable or system on or beneath the applicant’s land and in or upon all streets, roads or highways abutting said land. Such easement shall be granted for the purpose of serving the applicant or other customers of the company when such easement is necessary to provide service in the most safe, efficient and economical way possible. If the facilities are constructed underground, the company may record such. 5. The applicant agrees to comply with the payment terms and policies as may from time to time be determined and adopted by the company. Upon acceptance of Applicant’s application, and receipt of services from Company, Applicant shall become a patron of Company subject to the terms and provisions of RC Technologies Restated Articles of Incorporation and Bylaws, which shall constitute a contract between the Company and Applicant. A copy of Article 8, Cooperative Operation, of RC Technologies Bylaws is available upon request.*Please initial:If your account is listed only in your name, you may want to consider adding another name, if appropriate, e.g., a spouse or a roommate. If you are a parent or individual that relies on someone else to discuss account changes, payments, or anything else with our company, you will need to have that person’s name added to your account. The name does not need to be added to the billing name but can be added to our records as an authorized person for discussing information and making changes to your account.* No, I do not want to add any additional authorized contacts to my account. Yes, I would like to add authorized contacts for my account. Additional contact(s):I hereby apply for Voice / Video / Data services from RC Technologies, with the understanding that I am fully responsible for payment of the account. Your electronic signature will enter you into a binding contract with RC Technologies. Internet installation is free with a 24 month agreement. Early cancellation fees of $20.00 per month remaining in agreement will apply.* First Last Please include copy of Photo ID*Applications cannot be processed without a copy of photo ID.