Gtelco Request Form

Telephone Account Sign-up Request Form

Information

Name:
Email Address:
Address:
PO Box:
City, State, Zip:
Requested Number:	435-528
LD Carrier:
LD Carrier: (If Other was selected)
Account Type:

References

Previous Service Provider:
Previous Address:
City, State, Zip:
Phone Number:
1st Reference:
Address:
City, State, Zip:
2nd Reference:
Address:
City, State, Zip:


Options	$5.50 - Caller ID Free - Calling Name Delivery Blocking Free - Calling Number Delivery Blocking Free - Anonymous Call Rejection $2.50 - Call Waiting Free - Caller ID on Call Waiting Free - Cancel Call Waiting $2.50 - Call Forwarding (72) $2.50 - Call Forwarding to Fixed Destination $2.50 - Call Forwarding on Busy (90) $2.50 - Call Forwarding Don't Answer (92) Free - Call Forward Remote Access $2.00 - Toll Denied $3.00 - 3-Way Calling $2.00 - Residential Call Transfer $3.00 - Automatic Recall (69) $3.00 - Automatic Call Back (*66) $4.00 - Telemarketer Call Screening $3.00 - Teen Service (Distinctive Ringing) $4.00 - Enhanced Teen Service (Distinctive Ringing)	Free - 900 Restriction $4.00 - Non-Listed Number $5.00 - Non-Published/Non-Listed Number $6.00 - Voice Mail $5.00 - Single Number Service $4.00 - Conference Calling $4.00 - Notify Plus $2.00 - Call Logging $2.50 - Selective Call Forwarding $2.50 - Selective Call Rejection $2.50 - Selective Call Acceptance $2.50 - Selective Dist. Ringing/Call Waiting Free - Screening List Editing $2.00 - Speed Dialing (Short List) (74) $3.00 - Speed Dialing (Long List) (75) $3.00 - Ring Again $2.00 - Warm Line $3.00 - Customer Originated Trace (*57) $2.00 - Long Distance Alert $0.75 - Inside Wire Maintenance

Note: Should the account be assigned to an outside agency for collection, I/we (the subscriber) agree to pay all attorney fees, with or without suit, court costs, and a collection fee of 50% (fifty percent), which will be added to the outstanding balance of the account.

Bills are due and payable within 10 days of the billing date.

Comments or Questions:

Digital Signature:

Date:

A Gtelco representative will contact you to verify service request information and set an installation time. Gtelco requires that each customer provides a signed Telephone Account Sign-up form and pay a $100.00 deposit and $40.00 setup fee before service is installed. If you sign up for service via the Internet, please come to the Gunnison Telephone office at 29 South Main, Gunnison UT 84634 to pay the fee and sign the form.