Out of Exchange Service Agreement "*" indicates required fields Primary Account Holder* Secondary Account Holder Service Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Billing Address (if different than your service address) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Phone NumbersHome Phone NumberPrimary Account Holder's Cell Phone Number*Secondary Account Holder's Cell Phone NumberE-mail OptionsI would like to receive my monthly bill via* Email Paper I would like to receive promotional information via email Yes No Preferred Email With this agreement, I agree to maintain service(s) with Bernard Telephone & Communication Company, herein known as BTC, for a minimum of 12 Months. I understand that if I move or discontinue my selected service(s) within 12 months, I will be required to pay an early termination fee of $125.00. With this agreement, I understand I may receive equipment related to the delivery of service(s) that is the property of BTC. If this property is not returned in good operating condition upon discontinuation of the service(s), I will be charged full retail value. I am also responsible for any deliberate and out of normal usage damage to any BTC equipment. BTC will assess the damaged equipment and may charge up to full retail value for such damages. BTC reserves the right to change the rates, terms and conditions of this agreement at any time by providing me a written letter detailing those changes 30 days before their implementation. Any changes in the terms, conditions or rates will be sent by either US mail and/or email. If I do not request that my service(s) be discontinued, it will be presumed that I consent to the new terms, conditions or rates as notified. I also understand that it is my responsibility to protect my computer and network from viruses and other intrusive, damage causing software and people. If there is not up to date protection on my computer and I choose not to purchase virus protection through BTC, I will not hold BTC accountable for damages. Unless otherwise specified herein, services shall be available 24 hours a day, 7 days a week. There is always the possibility of system or equipment failures, or the need to temporarily interrupt your service(s) for system maintenance. BTC will try to restore failed service in a timely manner. Such temporary interruptions do not constitute a breach of contract and do not entitle the subscriber to a refund or credit of the monthly subscribed services. In addition, BTC will be held harmless any loss of compensation or income to the subscriber due to interrupted services. If, at any time, services are suspended due to non-payment or per customer request, a $15.00 reconnection fee will be applied to the account beyond the normal monthly service charge. I understand that BTC is not responsible for any service or content which may be accessed pursuant to this service or for any charges incurred as a result of access to such content or service. I understand that I am solely responsible for all use, content, downloads and/or charges related to these matters. I indemnify and hold harmless BTC from any and all costs, charges, or damages of any type of nature that I or any user of this account may sustain at any time. The service(s) provided to me by BTC may not be used for resale or re-transmission to other addresses without exclusive consent from BTC. I understand and allow BTC to login to, manage, or collect data usage reports in relation to BTC subscribed internet services.By signing below, I agree that I have received, read and understand the terms and conditions stated above. I also acknowledge and agree to be bound by all of the terms and conditions of this agreement. Please enter your initials* By initialing here, I certify I am the above signee and a false signature is forgery that is a federally punishable crime.Today's Date* MM slash DD slash YYYY In making this application the undersigned agrees to the rules and regulations of Bernard Telephone and Communications Company as set forth in the exchange tariff and to any general changes in rules, or rating for the service furnished under this application. This application becomes a contract when accepted in writing by the Telephone Company. In the event of dispute between the customer and the utility respecting any bill, charge or service, the utility shall forthwith make such investigation as shall be required by the particular case, and report the result thereof to the customer. In the event that the complaint is not resolved, the utility shall notify the customer that he has the privilege of appeal to the Commission as indicated in this rule and the utility or the customer may make an application to the Commission for Resolution of the complaint.Customer Proprietary Network InformationIt is Bernard Telephone Company’s responsibility under federal law to protect the confidentiality of your Customer Proprietary Network Information (CPNI). CPNI is any information that is not publicly available and includes the type of phone service you receive from Bernard Telephone Company, number of lines, amount of usage and calling detail.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 Bernard 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 Bernard Telephone Company and our affiliates about new products and services, packaged offerings and various promotions.CPNI* I DO NOT want my CPNI shared with Bernard Telephone Co. and their affiliates. I will allow my CPNI to be shared with Bernard Telephone Co. and their affiliates. Add Names for Approved AccessTo add a name for approved access to your account, please include it on the lines provided. For example, your spouse, parents, or children can be added.Name #1 & Phone Number Name #2 & Phone Number Name #3 & Phone Number Name #4 & Phone Number Password*Please create a password for your Bernard Telephone & Communications account. This will be used to verify we are being contacted by an authorized individual prior to making any changes to your account. There are no character requirements, so please use any password you like. Please answer two (2) authentication questions. You will be asked these questions in the event the password cannot be provided. If an authentication question is needed, a new form will be sent to the primary account holder at which time they will be instructed to change their password and update their authentication questions.Question #1*What is your favorite color?What is your mother's maiden name?What was your first pet's name?What was your favorite teacher's name?Who is your favorite sports team?Where is your favorite place to vacation?Answer #1* Question #2*What is your favorite color?What is your mother's maiden name?What was your first pet's name?What was your favorite teacher's name?Who is your favorite sports team?Where is your favorite place to vacation?Answer #2* Select ServiceInternet* 150 Meg = $59.95 300 Meg = $69.95 600 Meg = $79.95 1 Gig = $92.95 Video Service = $134.95* Yes No # of Televisions* Additional Set-Top Boxes = $6.00 each(Time & Materials will be charged if Set-Top Boxes are added after installation) DVR Service = $3.00* Yes No Optional A la carte services(Prices are on a per month basis) HBO = $20.00 Cinemax = $14.00 HBO & Cinemax = $32.00 Showtime = $10.99 Starz/Encore = $12.00 Leased Router Yes: $7.95/month + tax No Router Name* Router Password PhoneThis field is for validation purposes and should be left unchanged.
