Application (Inside) Please Select One:(Required)Residential/Non-BusinessSole ProprietorLLCNonprofitCorporationPartnershipPrevious Account Yes No Name:(Required) First Middle Last SSN:(Required)DOB:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Business Name: (If Applicable) EIN: 911 Service Address:(Required) Street Address Address Line 2 City 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 State ZIP Code Cell#:(Required)Work#:Email: Check if Billing Address is Different than Service Address: Same as Billing Address Different than Billing Address Billing Address:(Required) Street Address Address Line 2 City 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 State ZIP Code Spouse's Name First Last Spouse's Cell#Installation fee is $29.95 and is NOT refundable. Deposit is subject to credit history.Others authorized to make changes on my account.Name First Last Phone#Relationship to You Name First Last Phone#Relationship to You Click Here to Authorize More People Click Here to Authorize More People Name First Last Phone#Relationship to You Name First Last Phone#Relationship to You CPNI Notifcation:Under federal law, you have the right to confidentiality of information regarding your telephone services and NEMR has the duty to protect that confidentiality. This confidential information includes such things as specific services you purchase, the number of services purchased, who your provider is for a service, long distance call detail records, and charges related to the services purchased. This information is referred to as a Customer Proprietary Network Information (CPNI). Unless you check the "Opt-Out" box below, it will be assumed that NEMR has your approval to offer you products and services that you may find to be valuable additions to your existing services. You have the right to deny access to CPNI at any time by completing the CPNI Opt-Out form on our website. A denial will not affect the provision of any services. Any approval or denial of CPNI remains in effect until you revoke or limit such approval or denial. CPNI Password: WHAT CITY WERE YOU BORN IN?(Required) OPT-OUT: Unless you check this "Opt-Out" box, it will be assumed that Northeast Missouri Rural Telephone Company has your approval to offer you products and services that you may find to be valuable additions to your existing services. Membership AgreementThe Applicant hereby applies for membership in and agrees to take service from Northeast Missouri Rural Telephone Company (hereinafter called the “Corporation”) upon the following terms and conditions.1. The Applicant will be a member when they purchase service from Northeast Missouri Rural Telephone Company and live within the fourteen exchanges as set forth in the By-Laws.2. The Member agrees to comply with and be bound by the Articles of Incorporation and By-laws of the corporation and any rules and regulations adopted by the Board of Directors. The acceptance of this application by the Corporation shall constitute an agreement between the Applicant and the Corporation and shall continue in force until cancelled by notice given by either party to the other.3. You agree, in order for us to service your account or to collect any amounts you may owe, our organization’s representatives and vendors, as well as the representatives of our debt collection agency, may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you.4. Our organization’s representatives and vendors, and the representatives of our debt collection agency may also contact you by sending text messages or emails, using any e-mail address you provide to us. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I/We have read this disclosure and agree that the organization, its vendors, and its debt collection agents may contact me/us as described above:1) I am at least 18 years of age and have read and understand the Membership Agreement.2) Installation is $29.95 and is not refundable. Deposit is subject to credit check. 3) Construction cost, if needed, is $200 and must be paid in advance.Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Customer Signature(Required)Today's Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse SignatureINTERNETSELECT A PLAN TO MEET YOUR INTERNET AND/OR TELEPHONE NEEDSOption 1 - (w/o telephone) High Speed Internet Only - Download/Upload (Mbps)-GIGZILLA (Up to 1/1 Gbps) - $140TECHNOID (Up to 500/500 Mbps) - $115STREAMER (Up to 200/200 Mbps) - $85SURFER (Up to 100/100 Mbps) - $65CLASSIC (Up to 30/30 Mbps) - $55Option 2 - (w/telephone) High Speed Internet with Telephone- Download/Upload (Mbps)-GIGZILLA + TELEPHONE (Up to 1/1 Gbps) - $148TECHNOID + TELEPHONE (Up to 500/500 Mbps) - $123STREAMER + TELEPHONE (Up to 200/200 Mbps) - $93SURFER + TELEPHONE (Up to 100/100 Mbps) - $73CLASSIC + TELEPHONE (Up to 30/30 Mbps) - $63NEMR provides the Calix Gigaspire Router for Ultimate Wi-Fi management & experience for $7.95/mo.Extended ServicesAntivirus Protection for PC'sAre you interested? Yes No Security Camera SystemWould you like a quote? Yes No Hosted PBX for BusinessWould you like a quote? Yes No Static IPDo you require one? Yes No NEMR TV - (Contract Required)Select your TV Package (Choose 1)(Required)Not InterestedLocal Vu - $52.00Select Vu - $128.00Variety Tier - $132.00Ultimate Vu - $177.00Select your Movie Channels (Choose all that apply)(Required) Not Interested Cinemax - $11.00 Starz/Encore - $15.25 Showtime/TMC - $17.25 HBO - $16.25 Any 2 Movie Channels $32.00......Any 3 Movie Channels $44.00......Add Cinemax to Above $10.50NEMR TV Options (Choose all that apply)(Required) Not Interested DVR Service - $7.95/mo. Number of TV's to ConnectFirst STB (Set Top Box) is Free. Each additional STB is $5.95/mo.TelephonePlease choose one for Telephone Service(Required)I DO NOT want Telephone ServiceI would like Telephone ServiceUntitled LONG DISTANCE - Northeast Long Distance ($.13/min in state, $.10/min out-of-state) Free Feature: Call Waiting/Call Waiting on Caller ID/Call Forwarding/3-Way Calling/Speed Call 30 Inside Wire Maintenance ($1/mon.) Required with NEMR TV. Block International #'s (Free) VoiceMail ($2.95/mo.) Free Listing Block 900 #'s (Free) Unlisted Number ($1.60/mo.) Extra Listing ($1.45/mo.) Type Free Listing Here Type Extra Listing Here See a NEMR brochure for more telephone features not listed here or ask a customer service representative.Lifeline Progam and/or Affordable Connectivity ProgramYou may be eligible for assistance with your telephone or internet bill if you participate in one of the following:-Medicaid, Supplemental Security Income, Food Stamps, Low Income, Veterans Pension/Survivors Benefit Program, Federal Public Housing Assistance, and/or other assistance programs.Please select "YES" if you might be eligible. Our Lifeline coordinator will contact you.(Required)NO - I am not eligible.YES - I might be eligible.Enroll in Automatic PaymentsPlease Choose One(Required)I DO NOT wish to enroll in Paperless BillingI wish to enroll in Paperless BillingPaperless Billing Email(Required) Please Choose One(Required)I DO NOT wish to enroll in Automatic PaymentsI wish to enroll in Automatic PaymentsType of Account (Please select one)(Required)-Checking AccountSavings AccountDebit/Credit CardName(Required) First Last Customer Telephone(Required)Debit/Credit Card Number(Required) Expiration Date(Required) MM slash DD slash YYYY Security Code(Required) Name on Card(Required) First Last Name of Bank(Required) Bank's Telephone Number(Required)Bank's Transit/Routing Number(Required) Customer Bank Account Number(Required) By signing below, you are authorizing NEMR (Northeast Missouri Rural Telephone Company) to deduct from the above debit or credit card information for your monthly bill on the 10th of each month.NEMR will charge a $25 service fee for a rejected automatic payment. It is the customer's responsibility to notify NEMR of any payment changes.Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature(Required)How did you hear about NEMR?(Required)Please select one:WebsiteA Friend or Family MemberFacebookRadio AdNewspaper Ad or ArticleYard Sign or Other SignageDirect Mail (letter or postcard)Web AdAn EventBillboardTelevision AdDoor to Door SalesOtherPrevious ServiceLandlord/RealtorFriend or Family Member: Other:(Required) NEMR is an equal opportunity provider and employer. Reselling of NEMR Products and/or Services is prohibited per our company terms and conditions.