Customer Enrollment

Applicant Information

Primary Applicant

Secondary Applicant

Phone

Alternative Phone Number

Address

Do you Own or Rent This Location?

Own

Rent

Landlord Name

Mailing Address

Additional Authorized Individuals

Authorized User 1

Authorized Person’s Name

Phone Number

Authorized User 2

Authorized Person’s Name

Phone Number

Authorized User 3

Authorized Person’s Name

Phone Number

PIN/CPNI Information

In accordance with the Federal Communications Commissions (FCC) Customer Propriety Network Information (CPNI) rules, telephone companies are required to set up password protection for your account record. CPNI includes, where, when and to whom a customer places a call, as well as the types of service offering to which the customer subscribes and the extent to which the services are used. You will need to use a password when calling in to discuss any information that involves CPNI. According to FCC rules, only persons listed on your telephone bill can access or change information regarding your CPNI. You can add authorized users such as spouse, parents, children, employees, etc. to your account which would allow them to make changes or receive information about your account. They will need to know the password and/or verification questions to obtain any information regarding your account. As a customer, you have the right at any time to restrict the use of CPNI for marketing purposes. If you choose not to permit us to disclose your CPNI with Cochrane Cooperative Telephone Company and our affiliates, you may opt-out of receiving such information. The services you are currently receiving will not be affected if you opt-out, however, restricting CPNI may make you ineligible to receive information from Cochrane Co-op Telephone about new products and services, packaged offerings, and various promotions. If you do not want us to share your CPNI with Cochrane Co-op Telephone and our affiliates you can notify us in writing or call our business office at 608-248-2323. Once you opt-out you will remain on this list until you request otherwise.

4 Digit PIN to access your account

Please provide answers to both of the following security questions to verify your identity if the PIN is forgotten.

What is your favorite holiday?

What is your favorite color?

Service Information

Please place an “X” in the box corresponding to the applicable services you wish to sign up for. All information will be verified prior to billing of services.

High-Speed Symmetrical Internet

Telephone Service

Bundle both of my Internet and Telephone Services

High-Speed Symmetrical Internet

50/50 Mbps

100/100 Mbps

250/250 Mbps

500/500 Mbps

1/1Gbps

3/3 Gbps (call for pricing)

5/5 Gbps (call for pricing)

10/10 Gbps (call for pricing)

What do you want your Wi-Fi Network Name

What do you want your Wi-Fi Password to be

What type of service are you wanting

Residential Phone Service

Business Phone Service

Does this service request a toll-free (800, 888, 877, 866, 855, 844, or 833) number?

Yes

Do you want your number published (non-published are not in directory and do not show up on caller ID)?

Yes

If yes, how do you want the entry in the directory to read

Note: Our default entry will read: Last Name First Name Middle Initial (if sole applicant) or Last Name First Name & First Name of second applicant (if two applicants)

Do you want to bring your existing phone number as your phone number with CCT?

Yes

If yes, what is the number to port (bring over):

Note: there will be a $50 port fee unless part of grant expansion project

Do you want to have any long distance with your telephone service?

Yes

Please select all the features that you would like to have as part of your telephone service. Any options not selected will be blocked but can be turned on/off with a phone call to our office:

Caller ID with Name

Call Forwarding

Call Waiting with Name

Voicemail

Distinctive Ring

900 Toll Calling (dial 900 numbers)

International Calling

Note: Some services are only available in select markets. CCT staff will contact you if your selection is not available for the market you are located in.

Do you want to have a battery backup with your telephone service?

Yes

Note: During a power outage telephone service is not available without a backup battery. A backup battery may be purchased from CCT for $100.00. CCT will install and maintain the backup battery. The purpose of the backup battery is to provide telephone service for up to 24 hours in the event of a power outage. A wall mounted phone is required for service during a power outage; cordless phones will not work with backup battery. Those customers who are on life alert or a business account will receive this at no cost.

Billing Information

CCT provides monthly billing statements by email unless another format is requested. How do you want to receive your monthly billing statement? Select all that apply.

Billing Option

Mail to my address

Mail to this address

Deposit Information

CCT requires a deposit of $100 for all new customers which is held until you decide to terminate services or if your services are ever terminated due to non-payment. Please select how you will pay your deposit.

Deposit Option

I will pay by cash, check, or money order either before or at the time of connection.

I will pay online through CCT’s bill payment service before the time of connection.

Payment Information

Please select the method of payment you would like to pay your bill in:

Payment Option

I would like to pay by cash, check, money order, or use online bill payment service to pay monthly.

I would like to sign up for ACH to allow CCT to automatically debit my checking or savings account monthly.

I authorize Cochrane Co-op Telephone to deduct my billing payments from my checking/savings account listed above. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I understand that I control my payments and if at any time I decide to discontinue this service, I will notify Cochrane Co-op Telephone directly. If the balance in my account is not sufficient to cover the dollar value of the debit entry, a $15.00 returned payment fee will be added to my account, and may result in termination of the program. All information will remain confidential. I hereby acknowledge and agree that when I type my name in the space provided below, it serves as my electronic signature, and I intend to be legally bound by the content of the document to which this electronic signature is affixed. I understand that this electronic signature is considered the equivalent of my handwritten signature and holds the same legal validity and enforceability. By typing my name and proceeding, I am electronically signing and executing this document as of the date I affix my electronic signature.

Financial Institution (Bank) Name

Branch

Routing Number: (9-digit number located in the lower left corner of a check)

Account Number

Select the Type of Account

Personal Savings

Personal Checking

Business Savings

Business Checking

Authorization/Approval Section

I agree that the above information provided is true and accurate to the best of my knowledge and I further understand that any information falsely documented may constitute grounds for violation of local, state, or national laws and I could be subject to prosecution. I hereby acknowledge and agree that when I type my name in the space provided below, it serves as my electronic signature, and I intend to be legally bound by the content of the document to which this electronic signature is affixed. I understand that this electronic signature is considered the equivalent of my handwritten signature and holds the same legal validity and enforceability. By typing my name and proceeding, I am electronically signing and executing this document as of the date I affix my electronic signature.

Primary Applicant Signature(Required)

Date

Secondary Applicant Signature

Date

Customer Enrollment

Applicant Information

PIN/CPNI Information

Service Information

Billing Information

Deposit Information

Payment Information

Authorization/Approval Section

Mailing Address

Email Address

Phone Number

Quick links

Online Directory

Social Links