Application (Outside) Please Select One:(Required)Residential/Non-BusinessSole ProprietorLLCNonprofitCorporationPartnershipPrevious Account Yes No Name:(Required) First Middle Last DOB:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DOB:SSN:(Required) SSN:Business Name: (If Applicable)(Required) EIN:(Required) 911 Service Address(Required) 911 Service Address 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 check.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. SELECT PLANS TO MEET YOUR INTERNET AND/OR TELEPHONE NEEDSINTERNET-GIGZILLA (Up to 1/1 Gbps) - $140TECHNOID (Up to 500/500 Mbps) - $115STREAMER (Up to 200/200 Mbps) - $85SURFER (Up to 100/100 Mbps) - $65NEMR provides the Calix Gigaspire Router for Ultimate Wi-Fi management & experience for $7.95/mo.Telephone: $25/mo. includes Unlimited Long Distance! Keep your telephone number! Ask about FREE Calling Features! Yes No Listed in telephone directory?(Required) Yes No Antivirus 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 Affordable Connectivity Program (ACP)The Affordable Connectivity Program is a government program intended to make broadband services and connected internet devices affordable for low-income households.Please select "YES" if you might be eligible. Our ACP coordinator will contact you.NO - I am not eligible.YES - I might be eligible.Enroll in Automatic Payments and/or Paperless BillingGet a one-time $20 bill credit if you enroll in BOTH autopay and paperless billing plus $1 off your bill every month!Please 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) 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)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Terms of Service(Required) I agree to the terms of service. I am at least 18 years of age. I am aware this application is subject to credit check. Signature(Required)Today's Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How 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.
