Service Application & Order Form | United & Turtle Mountain Communications

Order & Service Application Form

Step 1 of 6

Are you a new customer?*
- Yes
- No

Business Name
Federal ID Number
Name*
First Last
Email*
Enter Email Confirm Email
Phone Number
Date of Birth*
Month
Day
YYYY
Do you live on Tribal lands?
- Yes
- No
Do you have a Tribal ID?
- Yes
- No
Do you qualify for the Affordable Connectivity Program (ACP)?*
Learn more about ACP here.
- Yes
- No
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
911 Address
Same as mailing address

Street Address Address Line 2 City State ZIP Code
CPNI Password*
A 4-digit security password for your account.
Housing Information*
- Own Home
- Rent Home
Landlord
Landlord Phone Number
Prior Resident
Prior Resident Phone
Employer*
Employer Phone
Nearest Relative*
First Last
Nearest Relative Phone*
Joint Application Information
Name
First Last
Date of Birth
Month
Day
Year

Consent Agreement*
I Agree
I (“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.
Date
Signature
Untitled
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 6

Joint Application Information

Advance payment will be directly applied to your account to help cover installation costs. This is not a deposit.

Internet, Television, & Phone - $305

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Phone - $35

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