Order & Service Application Form To apply for and order your services from United and Turtle Mountain Communications, please complete the following form. Step 1 of 5 20% Applicant Information* Business Residential Business Name Federal ID Number Name First Last Email Enter Email Confirm Email Phone NumberDate of Birth Month Day YYYY Tribal Enrollment(if applicable) Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 911 Address Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CPNI PasswordA 4-digit security password for your account. Housing Information Own Home Rent Home Landlord Landlord Phone NumberPrior Resident Prior Resident PhoneEmployer Employer PhoneNearest Relative First Last Nearest Relative PhoneJoint Application InformationName First Last Date of Birth Month Day Year Residential Services* Internet, Television, & Phone Internet & Television Internet & Phone Internet Phone & Television Phone Business Services* Internet, Television, & Phone Internet & Television Internet & Phone Internet Phone & Television Phone Advanced payment will be directly applied to your account to help cover installation costs. This is not a deposit. Internet, Television, & Phone - $305 Internet & Television - $270 Internet & Phone - $120 Internet - $120 Phone & Television - $185 Phone - $35 Choose your OptionsInternet speeds reflect both upload and download. Limited BasicTV: 30+ Channels Internet: 50 Mbps - $80.95 100 Mbps - $120.95 200 Mbps - $141.95 1 Gbps - $176.95 Business LiteTV: 80+ Channels Internet: 50 Mbps - $109.50 100 Mbps - $134.95 200 Mbps - $159.95 1 Gbps - $219.95 Limited Basic PACsTV: 30+ Channels Phone: Local Digital Telephone Service Internet: 50 Mbps - $90.95 100 Mbps - $130.95 200 Mbps - $151.95 1 Gbps - $186.95 Business Lite PACsTV: 80+ Channels Phone: Local Digital Telephone Service Internet: 50 Mbps - $131.95 100 Mbps - $156.95 200 Mbps - $181.95 1 Gbps - $241.95 TV + Phone Limited Basic - $51.95 TV: 30+ Channels Phone: Local Expanded Basic - $118.95 TV: 150+ Channels Phone: Local Unlimited Long Distance On-screen Caller ID 2 Calling Features Expanded Movie 1 - $127.95 TV: 150+ Channels Choice of 1 premium channel suite Phone: Local Unlimited Long Distance On-screen Caller ID 3 Calling Features Expanded Movie 2 - $145.95 TV: 150+ Channels Starz/Encore & Showtime/Movie Channel Phone: Local Unlimited Long Distance On-screen Caller ID 6 Calling Features TV + Phone Business Lite - $82.00 TV: 80+ Channels Phone: Local Business Basic - $107.00TV: 95+ Channels Phone: Local Unlimited Long Distance On-screen Caller ID 3 Calling Features Business Expanded - $122.00TV: 150+ Channels Phone: Local Unlimited Long Distance On-screen Caller ID 6 Calling Features Speed OptionsSpeeds reflect both upload and download. 50 Mbps - $59.95 100 Mbps - $84.95 200 Mbps - $109.95 1 Gbps - $169.95 Internet & PhonePhone: Local Internet: 50 Mbps - $72.45 100 Mbps - $97.45 200 Mbps - $122.45 1 Gbps - $182.45 Internet & PhonePhone: Local Internet: 50 Mbps - $81.95 100 Mbps - $106.95 200 Mbps - $131.95 1 Gbps - $191.95 Expanded BasicTV: 150+ Channels Internet: 50 Mbps - $142.95 100 Mbps - $180.95 200 Mbps - $196.95 1 Gbps - $236.95 Business BasicTV: 95+ Channels Internet: 50 Mbps - $134.50 100 Mbps - $159.95 200 Mbps - $184.95 1 Gbps - $244.95 Expanded Basic PACsTV: 150+ Channels Phone: Local Digital Telephone Service Unlimited Long Distance On-screen Caller ID 2 Calling Features Internet: 50 Mbps - $152.95 100 Mbps - $190.95 200 Mbps - $206.95 1 Gbps - $246.95 Business Basic PACsTV: 95+ Channels Phone: Local Digital Telephone Service Unlimited Long Distance On-screen Caller ID 3 Calling Features Internet: 50 Mbps - $156.95 100 Mbps - $181.95 200 Mbps - $206.95 1 Gbps - $266.95 Expanded Movie 1TV: 150+ Channels + One Premium Channel Suite Internet: 50 Mbps - $155.95 100 Mbps - $195.95 200 Mbps - $209.95 1 Gbps - $249.95 Business ExpandedTV: 150+ Channels Internet: 50 Mbps - $149.95 100 Mbps - $174.95 200 Mbps - $199.95 1 Gbps - $259.95 Expanded Movie 1 PACsTV: 150+ Channels + One Premium Channel SuitePhone: Local Digital Telephone Service Unlimited Long Distance On-screen Caller ID 3 Calling Features Internet: 50 Mbps - $165.95 100 Mbps - $205.95 200 Mbps - $219.95 1 Gbps - $259.95 Business Expanded PACsTV: 150+ Channels Phone: Local Digital Telephone Service Unlimited Long Distance On-screen Caller ID 6 Calling Features Internet: 50 Mbps - $171.95 100 Mbps - $196.95 200 Mbps - $221.95 1 Gbps - $281.95 Premium Channel Suite OptionsChoose one Starz/Encore Showtime/Movie Channel Expanded Movie 2TV: 150+ Channels + Starz/Encore & Showtime/Movie Channel Internet: 50 Mbps - $167.95 100 Mbps - $207.95 200 Mbps - $221.95 1 Gbps - $261.95 Expanded Movie 2 PACsTV: 150+ Channels + Starz/Encore & Showtime/Movie Channel Phone: Local Digital Telephone Service Unlimited Long Distance On-screen Caller ID 6 Calling FeaturesInternet: 50 Mbps - $177.95 100 Mbps - $217.95 200 Mbps - $231.95 1 Gbps - $271.95 Choose Your TV OptionsPremium Channel Suite OptionsChoose one Starz/Encore Showtime/Movie Channel Total Number of TVs to be ConnectedSet Top Box ($6 per TV)Enables your TV to access and display our digital TV service.cDVR (Cloud Digital Video Recorders)Saves recordings of your favorite TV shows so you can watch them anytime. cDVR Entry Level Package 250 GB - 3 simultaneous recordings ($0) 500 GB - 5 simultaneous recordings ($7.95 each) 1TB - 10 simultaneous recordings ($14.95 each) Premium Channels HBO – $20.00 Cinemax – $20.00 NFL RedZone (for the entire NFL season) – $55.00 Premium Channels NFL RedZone (for the entire NFL season) – $55.00 Stingray Music Channels – $30.00 per month TV Recording Tools Whole Home DVR – $5.99/month ManageMyTVs Mobile App – $1.00/month ManageMyTVs Web Access – $0 Choose Your Phone Options Business Line - $32.00 Residential Line - $22.50 Total Number of Phone Jacks Calling Features 3-Way Calling – $1.00 Anonymous Call Rejection *82 – $2.00 Auto Callback – $2.00 Auto Recall *69 – $2.00 Call Forwarding – $1.00 Call Forwarding Busy – $1.00 Call Forwarding Don’t Answer – $1.00 Caller ID Number Only – $2.00 Caller ID Name & Number – $4.00 Publish Non-List Non-Publish – $2.09 Linebacker (Insurance) Caller ID on Call Waiting – $6.00 Call Waiting – $1.00 Distinctive Ring – $5.00 Selective Call Rejection – $2.00 Toll Control with PIN – $2.50 Voicemail with PIN Toll Control PIN Voicemail PIN Voicemail Level Basic – $3.95 Basic Plus – $4.95 Premier – $5.95 Restrictions 3rd # Block 411 Block 900 # Block Caller ID Block Collect Call Block International Block Long Distance Block (Troll) Long Distance NDLD Long Distance Other Long Distance Carrier NDLD Long Distance Options NDLD Flat Rate NDLD $.10 Calling Plan Optional: NDLD Account CodePIN Long Distance Carrier Choose Your Internet OptionsCurrent UTMA Internet Subscriber? Yes No Total Number of Computers to Connect I have my own equipment (modem, router, etc.) Number of Static IP Addresses$15.00Managed WirelessSpecialized high-power equipment for stronger Wi-Fi signals throughout every corner of their home, garage, or yard. Managed Wireless – $5.99/month * Managed Wireless Required Managed Wireless Extender – $3.99/month * Managed Wireless RequiredProtection ToolsCybersecurity protection tools for your computers and mobile devices to safeguard your computer, files, and private information. SecureIT PlusAnti-virus software and internet security.$4.95/month - per deviceFileHopper 5GBOnline storage and backup software for your files. $2.95/month - per deviceFileHopper 50GBOnline storage and backup software for your files. $5.95/month - per deviceFileHopper 250GBOnline storage and backup software for your files.$14.95/month - per devicePassword GeniePassword management and security software. $1.75/month - per deviceProtection Plus PlanMaintenance coverage of phone, internet & TV communications wiring Per line – $2.00/month Consent Agreement* I AgreeI (“Customer”) understand that if service is disconnected and reconnected for any reason, reconnect charges will apply. I also understand UTMA & TMC’s equipment will be returned immediately upon termination of service. I agree to be bound by UTMA & TMC’s Terms & Conditions (“T&C”) as published on utma.com. My continued use of the service shall be considered my consent to any amendments that may be made to the T&C. I understand that surge and firewall protection are my responsibility, and I agree that I will be responsible for any and all damages or losses. I understand that the router provided in Managed Wireless service and the Managed Wireless Extender equipment are the property of UC and TMC, and I will be charged $225 for the router and an additional $105 for the Managed Wireless Extender if services are disconnected and the equipment is not returned in good working condition. I understand that set-top boxes are the property of UC and TMC, and are due back upon disconnection of services. If not returned, fees will be applied. Long Distance - I grant UTMA/TMC authority to change my long-distance provider as needed to provide service in the bundle selected above. It has been explained to me and I understand that the package price listed on this application and in all other UTMA & TMC materials does not include mandatory fees and taxes. I understand my bill will be larger than the package price due to these charges. DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SignatureCommentsThis field is for validation purposes and should be left unchanged.