Application - New Telephone Only Service

Telephone Service Only
All questions marked with * are required.
Account # (For Business use only)
Please specify the Customer Care Specialist that you spoke with *
Basic Telephone Service is $15.00/month *excluding taxes and fee's

Schedule of Charges:

Service Order $10.00

Line Connection $10.00

Premise Visit $30.00

Taxes $1.60

Deposit $100.00 and up
Full Legal Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Drivers License #
Service Address *

Street Address

Street Address Line 2

City State

Zip Code
County *
Subdivision
Has there been service at this address before? *
Is electric run to the house? *
Where is your electric meter located? *
Contact Number *

Area Code Phone Number
Is this a.. *

Home Phone Cell Phone Work Phone
Contact Number *

Area Code Phone Number
Is this a.. *

Home Phone Cell Phone Work Phone
E-mail *
Do you Own or rent this property? *

Own Rent
If renting, please provide Landlord Name and Contact #
Spouse Name (or other name on account)

First Name Last Name
Spouse Contact Number

Area Code Phone Number
Spouse Date of Birth

Month Day Year
Have you or your spouse had service with EMPOWER Telecom before? *
Employer? *
Next of Kin (name and contact # *
Do jacks need to be installed? *if no, select 0, if yes, select # of jacks *
Jack installation requires 2 technicians, billed at $55/hour per technician
Do you wish to sign up for eBill (paperless) billing? *

Yes, I want to sign up eBill and receive a paper statement Yes, I want to sign up for eBill and go paperless No, I do not want to sign up for eBill. I wish to receive a paper statement in the mail.
Billing Address (if different from Service Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please select the features (if any) you would like to add to your service *

NONE Basic Long Distance @ 9.9¢/min Unlimited Long Distance @ $49.95 (for phone and Long Distance) Non-Listed Number @ $1.25/mo Non-Published Number @ $1.25/mo Inside Wire Maintenance @ $3.99/mo. Pre-Inspection of house wiring is required Caller ID (Name & Number) @ $6.00/mo Voicemail @ $5.00/mo Call Waiting (with cancel call waiting) @ $1.50/mo Three Way Calling @ $2.00/mo Call Forwarding @ $1.50/mo
CPNI

CPNI is a communications industry abbreviation that stands for Customer Proprietary Network Information. CPNI refers to your telephone service, including the charges on your bill, the services you subscribe to, and your usage data and calling patterns.

For more information, please click here to read the CPNI guide lines.
Please list any other individuals you are granting permission to access this account *
Separate multiple names with comma ,
For account security, please select a secure question to answer: *
You will answer this question below.
Please answer your question above *
Please answer the question you selected above
Best Days for Installation *

Monday Tuesday Wednesday Thursday Friday
Best Times for Installation *

8am-10am 10am-12pm 1pm-3pm 3pm-5pm
How did you hear about us? *

EMPOWER Website Facebook Instagram Marquee Sign Billboard Yard Sign Web Search Directory Newsletter CSR Technician Neighbor
I understand that my security deposit will be refunded to me after twelve (12) consecutive months of satisfactory credit without any late notices or returned checks. If a late notice, payment arrangement or return check is issued against my account I understand that the twelve (12) month period will start again from that date. Please type your full name to acknowledge and agree to the terms and conditions of the EMPOWER Telecom Service Agreement *
Signature

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Telephone Service Only

All questions marked with * are required.