DATE: ________________        BILLING NUMBER: 503.845. _______     BROADBAND NUMBER: 503.845. _______
NAME: ___________________________________________________________________________________________
SERVICE ADDRESS: _______________________________________________________________________________
BILLING ADDRESS: _______________________________________________________________________________
Please check the applicable BROADBAND INTERNET Service:

BROADBAND SERVICE, INCLUDES INTERNET

SpeedChoice Bundle - Residential
Includes 3.0M high speed internet, local access line, Call Waiting, Call Forwarding, Three Way Calling, and Caller ID
$ 44.95 mo.
XtremeSpeed Bundle - Residential
Includes 6.0M high speed internet, unlimited e-mail accounts, local access line, Call Waiting, Call Forwarding, Three Way Calling, Caller ID and Voice Mail.
$ 49.95 mo.
XtremeSpeed Plus Bundle - Residential
Includes10.0M high speed internet, unlimited e-mail accounts, local access line, and Ten Calling Features.
$ 59.95 mo.
 
Gold - ADSL 3.0 Mbps down/1Mbps up
$ 39.95 mo.
Diamond - ADSL 6.0 Mbps down/1Mbps up
$ 49.95 mo.
Diamond Plus - ADSL 10 Mbps down/1Mbps up
$ 54.95 mo.
Static IP Address (SEE QUESTION 6, BELOW)
$  8.00 mo.
Non-Recurring Charge (New mtangel.net customers only)
$ 15.00
Customer Request Charge
$ 10.00
Modem with one in-line filter (Regular price $64.95)
Free
Wi-Fi wireless Router see page two
$ 3.95 mo.
Option: Wi-Fi wireless Router see page two
$ 69.00
In-line filters, price each
$ 3.90
Activation fee is $99.00. Activation fee is waived when customer commits to retain service for a minimum 12 month period. If service is disconnected for any reason during the 12 month commitment period, the installation charge will apply.
I understand and agree to the Terms and Conditions of the BROADBAND INTERNET Service Agreement.
__________________________________________________________________________________________________
Authorized Signature            Date
PLEASE ANSWER THE FOLLOWING QUESTIONS:

1) DSL service for a desktop computer comes with a free modem.

2) How many telephones do you have on that line? ____

3) Do you have any wall phone jacks? ____ Yes ____ No   How Many? ____

4) Does your computer have a NIC card? (Network Interface Card) ____ Yes ____ No

5) How many computers will you be hooking up to DSL? ____ For multiple computers, the Wi-Fi wireless router can be used with up to four (4) wired computers and more than one hundred (100) multiple wireless connections. The Wi-Fi wireless router can be leased for $3.95 month or purchased for $69.99. Purchase of router includes a one year warranty.

6) If you require wireless service will you be purchasing a Wi-Fi wireless router from Mt. Angel Telephone? ____Yes ____No

7) Do you have a telephone jack with dial tone at the location the DSL modem will be set? ____ Yes ____ No

8) For Static IP Address, what is the MAC Address of the equipment that will have the Static IP on it?

9) Does your business or residence have an alarm system? ____Yes ____No

______________________________________________________________________________
XtremeSpeed Plus Bundle - Includes ten (10) Calling Features:

____ Anonymous Call Rejection *77 Prevents telephone numbers with the Line Block features from ringing your telephone.

____ Call Blocking *67 Prevents your telephone number from being displayed on Caller ID.

____ Call Forwarding *72 Allows your phone to transfer incoming calls to another number.

____ Caller ID Allows you to see incoming number and/or name of the caller.

____ Call Rejection *60 Allows you to reject calls from specific numbers so you are not bothered with unwanted calls.

____ Cancel Call Waiting *70 Allows you to deactivate the Call Waiting feature to avoid interruption during a call.

____ Call Waiting Alerts you of an incoming call while you are on the phone.

____ Selective Call Forwarding *63 Allows you to create a select list of number that will ring to a forwarded number.

____ Three Way Calling Enables you to turn a two-way telephone call into a three-way conversation.

____ Voice Mail Never miss an important call! Voice Mail answers the phone, plays a personalized greeting and records the caller's message. All messages are time and date stamped.

See pages 25 - 29 of North Willamette Valley directory for description of services.

Rev: 01/03/11