NEMR 2nd Line Application Step 1 of 2 50% Please Select One:(Required)Residential/Non-BusinessSole ProprietorLLCNonprofitCorporationPartnershipBusiness Name: (If Applicable) EIN: Member Name(Required) First Last Cell#:(Required)Home#:(Required)Email: Select Services: (Select all that apply)(Required) Internet Television Telephone 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 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 Installation fee is $50.00 and is NOT refundable. Deposit is subject to credit history.INTERNETPlease select one from either Option 1 or Option 2Option 1 - (w/o telephone) High Speed Internet Only - Download/Upload (Mbps)Not InterestedGIGZILLA (Up to 1/1 Gbps) - $140TECHNOID (Up to 500/500 Mbps) - $115STREAMER (Up to 200/200 Mbps) - $85SURFER (Up to 100/100 Mbps) - $65Option 2 - (w/telephone) High Speed Internet with Telephone- Download/Upload (Mbps)Not InterestedGIGZILLA + 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) - $73*Telephone charges are not exact due to estimated taxesNEMR provides the Calix Gigaspire Router for Ultimate Wi-Fi management & experience for $7.95/mo.NEMR TVSelect 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) Not Interested Cinemax - $11.00 Starz/Encore - $15.25 Showtime/TMC - $17.25 HBO - $16.25 NEMR TV Options (Choose all that apply) 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 3'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.Todays Date:(Required) MM slash DD slash YYYY Customer Signature:(Required) Enroll in Automatic PaymentsPlease 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)Address of Bank(Required) Street Address Address Line 2 City MissouriAlabamaAlaskaAmerican 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 Customer Bank Account Number(Required) Bank's Transit/Routing Number(Required) This is to Authorize NEMR to deduct my monthly bill from the above account on the 10th of each month according to the information provided above. **Note: Denied credit card payment could result in a $20 charge. Customer's Signature(Required)Today's Date(Required) MM slash DD slash YYYY NEMR is an equal opportunity provider and employer. Reselling of NEMR Products and/or Services is prohibited per our company terms and conditions.
