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Application for CATV Service |
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Name of Applicant
_________________________________________________________________ |
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Last _______________________ |
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First _______________________ |
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Initial ________________ |
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Mail Bills To: |
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Address ____________________________ |
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Physical Address ______________________
___________________________________
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City _______________________________ |
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City _________________________________ |
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State, Zip ___________________________ |
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Phone _____________________________ |
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Spouse ______________________________ |
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Social Security Number
__________________________________ |
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Spouse's Social Security Number
_____________________________________ |
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Driver's
License Number _____________________________________________________________ |
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Location (include 911 address, color of residence,
exact location)
_________________________________________________________________________________
_________________________________________________________________________________
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For Office Use Only -- New Applicants Only
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Own |
Rent |
Lease |
Other |
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No. of Sets |
Service Monthly Charge
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Hook-up Fee |
Deposit |
Other |
Total |
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(The
applicant for the requested service and equipment, and for such additional services
or equipment as may be ordered later, agrees to pay established rates for all
such services and equipment. In making this application, the undersigned agrees
to the rules and regulations of the CATV company as set forth in the Rules and
Regulations and to any general changes in the rules, regulations, or rates for
the service furnished under this application. The undersigned further grants
the company the right of easement over, above, on or under the premises in order
to construct, reconstruct, operate and maintain a TV line or system; and to
license, permit, or otherwise agree to the joint use or occupancy of poles of
said line or system by any other person, firm or corporation for TV or electrification
purposes. The undersigned has also read the Privacy Notice and the company agrees
to abide by it. This application becomes a contract when accepted in writing
by the CATV company.) |
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Application
Taken By ________________________________________________________________ |
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Applicant
Name ____________________________________________________________________ |
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Approved
By _______________________________ |
Date
____________ |
By
__________________ |
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Additional Information Requested for New Installations/Reconnection of TV
Service Please list one friend or relative with a telephone number. |
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Name ________________________________ |
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Phone ___________________________________ |
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Address ______________________________
______________________________
______________________________
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Relationship _______________________________ |
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City _________________________________ |
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State __________ |
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Zip _____________________ |
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Miscellaneous ______________________________________________________________________ |
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Applicant's Name ___________________________________________________________________ |
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Certification
In hereby give Inter Mountain Cable, Inc., the right to make a thorough
investigation of my credit history, and I release from all liability all persons,
companies, schools, and corporations supplying such information I indemnify
Inter Mountain Cable Inc., against any liability which might result from making
such investigation. I agree that Inter Mountain Cable, Inc., may obtain a consumer
report of other information regarding me and may consult its own files for my
credit report. I understand that any false answer of statements or implications
made by me in this application or other required documents shall be considered
sufficient cause for denial of service. |
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Name ___________________________________ |
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Date _________________________________ |
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Witness __________________________________________________________________________
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Additional Voluntary Information
-- Application for CATV Service
The data is being collected for Federal Government Reporting Purposes only and
you have the option to provide or not to provide this information. If you choose
not to provide the requested data, the company may determine your race or ethnic
background based on their knowledge of the service area. |
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Racial/Ethnic Group:
A. ____White (not of Hispanic Origin)
B. ____Hispanic
C. ____Asian or Pacific Islander
D. ____Black (not of Hispanic Origin)
E. ____American Indian or Alaska Native
F. ____Other (specify) _______________________________________________________________ |
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United States Department of Agriculture
Rural Electrification Administration
Appendix C Statement of Nondiscrimination
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Tel-Com,
Inc., is the recipient of Federal financial assistance from the Rural Electrification
Administration, an agency of the U.S. Department of Agriculture, and is subject
to the provisions of Title VI of the Civil Rights Act of 1964, as amended, Section
504 of the Rehabilitation Act of 1973, as amended, the Age Discrimination Act
of 1975, as amended, and the rules and regulations of the U.S. Department of
Agriculture which provides that no person in the United States on the basis
of race, color, national origin, age or handicap shall be excluded from participation
in, admission or access to, denied the benefits of, or otherwise be subjected
to discrimination under any of this organization's programs or activities. The
person responsible for coordinating this organization's Non-discrimination compliance
efforts is Nell Davis, Administrative Assistant. Any individual, or specific
class of individuals who feels that this organization has subjected them to
discrimination may obtain further information about the statutes and regulations
listed above from and/or file a written complaint with this organization; or
the Secretary, U.S. Department of Agriculture, Washington, D.C., 20250. Complaints
must be filed within 180 days after the alleged discrimination. Confidentiality
will be maintained to the extent possible. |
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Tel-Com, Inc.
Box 159
Harold, KY 41635 |
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Subscriber Policy Notice -- Revised 07-07-1985 |
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As a subscriber of cable services, you are entitled under federal law
to know the following:
(1) In order that we may continue to provide reliable, high quality service
to you, we keep regular business records that contain your name, address,
and other personally identifiable information. Such records include billing,
payment and deposit records, records indicating the number of television sets
connected to cable, and the service options you have chosen. We use this information
to make sure that you are being properly billed for the services you receive.
(2) We consider information we keep to be confidential. We may collect
personally identifiable information from you and may disclose it to a
third party if (a) you consent in advance in writing; or electronically;
(b) disclosure is necessary to render cable service and other services
we provide to you and related business activities; or (c) disclose your
names and addresses to a collection service if required to collect past
due bills.
(3) Unless you object, from time to time, we may disclose your name and address
for mailing lists and other purposes. We will not disclose the extent of your
viewing or use of a particular service or nature of any transaction you make
over the cable system, but we may disclose that you are among those who subscribe
to a particular service. If you wish to remove your name from such lists or
limit the use of your name at any time, please contact us at the system office.
(4) We may also electronically test the system from time to time to
determine whether you are being properly billed for the cable services
you are receiving.
(5) We will maintain information about you for as long as we provide
service to you, and for a longer time if necessary for related business
activities. When information is no longer necessary for our purposes,
we will destroy the information unless there is a legitimate request or
order to inspect the information still outstanding.
(6) You have the right to inspect our records that contain information
about you, correct any error in our information, and enforce your rights
under federal law. If you wish to inspect the records at our system office
pertaining to you, please contact us to set up an appointment during regular
business hours at the above address or one of the telephone numbers listed.
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