Residential Application for Service - Bush
BUSH.TELL. INC.
Box 109
. Aniak, Alaska 99557 .
(907) 675-4311
RESIDENTIAI, APPLICATION T'OR SERVICE
NAME
LAST
M]DDLE INlTIAL
FIRST
DATE OF BIRTH
S.S.N.
MAILING ADDRESS
CITY
STREITr?.O BOX
WOULD YOU
LIKI TO HAVE YOUR
ZIP CODE
PHONE NLJMBER PUBLISHED? Y
NAME TO BE L]STED IN T1.IE PI]ONL DIRICTORY
HAVE YOU EVER HAD AN ACCOUNT WITH BUSH,TELL, INC.? IF YES. WHAT WERE TIIE N,\ME(S) &
A((otNT
rt vgtxrsr
WHAT IS THts LOCATION OF YOUR HOME. OR PI ACI OF lNSTALLATION
CREDfI REFERI.-]NCES
PI-EASI] I-1ST PRI;VIOUS PHONE OR POWER COMPAN{ES THA]' YOU HAVF] HAD ACCOTJNTS WITII. IF
t]NAVAIT-ABLE. PLEASI] LIST OTHER BUSINESSgS THAT HAVF: GRANTED YOU CRIDIT.
COMPANY NAME
COMPANY ADDRESS & PHONE NUMBER
COMPANY NAME
COMPANY ADDRI]SS & PHONE NLIMBER
COMPANY NAME
COMPANY ADDRESS & PHONE NL,MBER
PRESENT EMPLOYER
PHONFJ #
II EASF] RI]AI) I'I IF F]N I I I'F] A1)P],]CA I ION AN I) I.'II-I OUT ACCORDINCLY. II THIS APPI,ICAI'IoN IS ACC]EI I LD. IHE
APIL]CANT(S) IS/ARE DEE\IED TO HAVE AGREED TO PAY IN I]ULL. ON I]A('I ] MONTIII,Y 51A I'IN'1F]NT. \\lTHIN I5
DAYS OI THE RECEIPT
THIRIOI
APPL]CANT SIGNATURE
DATE
CO-APPLICANT SIGNATURE
DATE
FOR BUSH-TELL. INC. USE ONLY
NUI\IBER(S) ASSICNED
BY
BUSH-TI'LL.INC.
RESIDENTIAL QUESTIONNAIRE
HOW MANY LINES WOULD YOU L]KE?
LOCATION OF THE HOIJSE WHERE THE TELEPHONE WILL BE INSTALLED
HAS TIIE BUILDINC EVER HAD A'I1-:I,EPHONF]
LINL? Y
N
]F YES, WHAT WAS TT]E PREVIOIJS PHONE NUMBER FOR TI-]E BUILDING?
DOES THE BU]LDING NEED WIRING OR A
DOES THE BU]LDING NEED
ADD]'IIONAL
JACI(? Y
WIR]NG? Y
N
N
IF YES, WHERE?
IS THERE A CONTACT NAME AND NUMBER WIIERE WE CAN REACH YOU FOR ANY O1'HER ADDITIONAL
INFORMAT]ON WE M]GHTNEED?
IF THERE ARE ANY CHANGES NEEDED TO THIS ACCOUNT WHO ARE THE AUTHORIZED
PERSONI\EL TIIAT CAN APPLY IHESE CHANGES?
LIST ALL HOUSEHOLD MEMBERS
BUSH-TELL. INC.
SPECIAL TELEPLIONE SERVICIS
AS A CUSTOMER OF BUSH-TILL. INC., YOU ARE GlVEN TIIE CI IOICE OF FOUR TOLL BILLING EXCEPT]ONS.
PLEASL CHECK ONLY
q\E
OPTIONI
* ACCEPT THIRI] PAR'IY AND COLLECI'CALLS
+
DENY COLLECT CALLS
* DENY THIRD PARTY CALLS
+
DENY BOTH THIRD PARTY AND COI,I-ECT CALLS
ALONC WITH THE TOLL BILLING EXCEPT1ONS, WT.] PROVIDE VARIOUS CUSTOM CALLING FEATURES.
EACH AT S I.5O A MONTH. FOR ONLY 55.OO A MONI'H YOU CAN SUBSCR]I]h I'O ALL OF TL]ESE FE,\TURES.
YOU MAY CIIECK ONE OR MORE OF TI-IE FOLLOWINC SELEC'IIONS,
* CALL FORWARDJNG
* CALL. WAITING
+
TIJREE-WAY CALLING OR CONFERENCE CALL]NG
+
WAK[-UP CALL
* SPEED D]ALINC
* LASI NUMBER RIDIAL
* PLEASF] PLACE ALL FL]AIURES ON l'HE LINE
* I DO NO]'WISH TO SUBSCRIBI-]'IO ANY IIATURES
*** CALLER r.D. (S3.95 A MONTH)
*** CALLER I.D. BLOCK]NG (IRLE)
* cLASS FEA |URE PACKACE l ($9.95)
,CA1,L,I]R ID
,AI]'TOMATIC REDIAL
-DISTINCIIVh RINGING/CALL WAI'f lNC
.ANONYMOUS CALL REJECTION
* cLASS FEATURE PACKAGE 2
(S
12.45)
CALLER II)
,AUTOMA'TIC REDIAL
,DISTINCTIVE R]NCINGJCALL WAITlNC
,ANONYMOUS CALL REJECTION
,SELECTIVE CALL FORWARDlNG
-SELECTIVE CALL REJECTION
WOULD YOU LIKE ANY RESTRICTIONS ON YOUR LINE? PLEASE CHECK ON1-Y
9N!
OPTION.
I3]I
FOR OPERATOR ASSISTED LONG DISTANCE CALLS & CALLING CARD USD, NO DIRECT
I,
DIALIN"G LONG DISTANCE. EXCLPT TOLL FREE NUMBF]RS
2, I8.tOI FOR LOCAL CALLS ONLY, NO ACCESS 1'O OPERAI'OR OR USE OF A CALL]NG CARD,
EXCtsP'I I'OLL FREE NUMBERS (LOCAL ONLY)
3. NO RESTRICTIONS
DIRICT DIAL
BUSH.TELL. INC.
CHA]IGES I]OR TELEPHONE CONNECTION
APPROVED BY ALASKA PUBLIC UTILITIES COMMISSION
DECEMBER 20, I985
INITIAL SERVICI ORDER...SI5.OO THIS APPLIES TO WORK DONE, RECEIVINC, RECORDING AND
PROCESSINC TNIORMATION NECESSARY TO [XECUTE A CUSTOMER'S REQUEST FOR THE IN] IIAL,
ESTABLISHMENT OT TELEPHONT] SERVICg,
ST]
BSEQUENT SERVICE ORDER...SI2.5O THIS APPLIES TO ADDITIONS, MOVES OR CHANGES TO EXISI ING
SERVICE.
LINE CONNECTION,,.S22.5O APPLIES 'I'O WORK DONE IN TI IE CENTRAL OFFICE AND STATION
PROTECTOR IN CONJUNCTION WITIIPROV]D1NC AN ACCESS LINE. TIIIS CHARGE INCLUDES THE
RE-ESTABLISHMENT OF SERVlCE.
INSTALLATION...$.10.35 MINIMUM OF FIALF HOUR I,ABOR (:580.70 PER HOUR) APPLICABLE FOR WORI(
DONE TO INSTALL, EXTEND, MOVE OR REPAIR WIR]NG ON THE CUSTOMER'S S]DE OF THE ]NTERFACI:,
TH]S CHARGE ]S APPLTCABLE ONLY AT CUSTOMIJR'S REQUtrST.
NUMBIR CHANGtr...S22.5O LINtr CONNECTION...$15,00 SERVICE ORDER FEI CUSTOMER WILL BE
REQUIRED TO FILL OUT A NEW APPLICATION FOR SERV]CE. IF I'HERE ARE ANY OUTSTANDING
BALANCES DUE TO BUSH,TELL, ]NC. TI1AT TOTAL MUST IIRS'I BL PAID IN TULL BEFORE BUSH-TELL, INC.
WILL CIIANGE THE PI'IONE NUMBER.
DIRECTORY SERVICE
ALL CTJSTOMERS WILL IIAVI ONE LIST]NC
LISTING WILL COST $I.OO.
PER TELEPHONE
L]NE IN IHE DIRHCTORY. ADDITIONAL
UNPUBLISHtrD SERVICE...S5.OO A ONE TIME CIIARCE, A'I THE SUBSCRIBERS REQI]EST THE PHONE
NUMBER WILL NOT BE LISTID IN EITHLR THE LOCAL DIRECTORY OR DIRECI'ORY ASSISTANCI.
YOS.
APPLICANT SIGNATURE
I TIAVE RDAD AND UNDERSTAND ALL CHARGES
DATE
BUSH-TILL. INC.
RIGHTS CONCERNING I]NPUBLISHED PHONE NUMBERS
IF YOU HAVE CHOSEN TO HAVE AN UNPUI'LTSHED NUI\{BER. PLEASE READ THE FOLLOWING:
THE FEDERAL COMMUNICATIONS COMMISSION IFCC) HAS ISSUED,\ RULING WTIICII ALLOWS BUSHTELL, ]NC. TO RELEASE TI]E BILLINC NAME AND ADDRESS OF UNBPUBL]SIIED NUMBERS TO LONG
DISTANCE CARRIERS WI.IO DO NOT HAVE A BlLLING CONTRACT WITH BUSII-TELL, INC. IN ORDER FOR
TI-IEM TO ASS]GN T\ND BILL THL CORRECT PARTY FOR THIRD PARTY \TJMBERS AND COLLECT CALLS.
THIS INFORMAT]ON MAY ALSO BE USED FOR VERIFICATION OII PRE-SUBSCRIPTION. NEW ADDRESS
PURPOSES, FRAUD PREVENTION AND SIMILAR NON-MARI{ETING PURPOSES,
TI.IIS RULIN6 DOES NOT AFFECT YOUR PRIVACY AS RELATED TO PUBLIC,A.TION IN TELEPHONE
DIRECTORIES OR RDLEASE OI THIS INTORMAT]ON TI.iROUG}I DIRECTORY SERVICES. TIIE ]NFORMATION
IS RELEASED SOLEY TOR BILI,ING AND CUS'I'OMER PROTECTION SERVICES.
IF YOU CHOOSE NO'I' 1O HAVF: YOUR BILLINC NAME AND ADDRESS RELEASED BUS]'I-TELL. INC. CAN
PLACE RES-I'RICTIONS SO THAT THIRD PARTY AND COLLECT CALLS CANNOT BE MADI IiROM YOUR
TLLEPHONE NUMBIR. THUS ET,IMINAT]NG I'HE NEED TO PROVIDE A LONG D]STANCE CARRIER WITII
SUCH INFORMAl'ION.
THIS IS TO ADVISE BUSII-TELL. INC. TIIAT UNDER NO CIRCUMSTANCES IS MY BIt.LINC NAME AND/OR
ADDRESS INFORM,\TION TO BE RELEASED TO,\NYONE FOR ANY PURPOSE AT ANY TIME,
I UNDERSTAND THA'T I WILL NOT I]E AI}LE TO PLACE THIRD PARTY CALLS AND COLLECT CALLS ON
MY 1'ELEPHONE NUMBtrR
APPLICANT SIGN,ATURE
DATE
BUSH-TELL. INC.
.900" PAY-PER.CALL CUSTONIER SERVICE RIGIITS
IF YOU BELIEVE YOUR BILL lIAS AN ERROR RELATED TO "9OO" PAY,PER-CALL SERV]CE CHARCES YOU
MAY INITIATE A REVIEW OF THE ERROR BY CALLING BUSI]-TELL. INC. AT (907) 675-,I3I I WIIHIN 60 ])AYS
AFTER Tl{E DATE OF THE FIRST BILL THAT CONTAINS THE ERROR.
YOU MAY ALSO CALL BUSH.'I'ET,L, INC.]'O OBTAIN ANSWERS TO QUESTIONS AND INFORMATION ON
CUSTOMER RIGHTS AND OBI,IGA'IIONS WfTH RECARD TO THI USE OF "900" PAY-PER-CALLS SERVICES,
OR TO OBTATN THE NAME AND MAII-ING ADDRESS OF THE "900" PAY-PER-CALL SERVICE PROVIDER.
CHARGES I'OR "900" PAY-PER,CAI,L SERVICI]S ARE FOR NON-TELECOMMUNICATTON SERVICES. FOR '900"
PAY-PER-CALL BILL]NC ERRORS. YOU HAVE 'THE RIGHT TO WITHHOLD PAYMENT OF THE DISPUI'EI)
CI{ARGES DURINC 'TH E BILLINC EITROR REVIEW. YOUR LOCAL AND LONG DISTANCE TELEPHONE
SERVICE CANNOT BE DISCONNECTED FOR FAILURE TO PAY TLIE "900" PAY-PER-CALL SERVICE CHARGES.
AND NO COLLEC]ION ACl'IVII'Y WILI, OCCUR WHILE TIIE BILL]NG IS UNDER REV]EW,
THE "9OO'' PAY-PER-CALL SERVICE PROVIDER MAY EXERCISE ITS R]GHT TO COLLECT FOR LEGITIMATE
CHARGES. ACCESS TO "900" PAY-PIR-CALL SERVICES MAY BE BLOCKED AT YOUR RIQUIST OR FOR
FAILIJRE TO PAY LEGITIMATE CHARGES.
IF YOU WISH TO BLOCK'9O()'' CALLS ON YOUR PHONE. YOU NIED TO CALL I-8OO-478-9OOO. ANY
CUSTOMER SERVICE REPRESENTAT]VE ]N THE RESIDENTIAL SERVICL ARF]A CAN ASSIST YOU.
YES,I HAVE READ THtr ABOVtr PARAGRAPHS AND Y[S, I UNDIRSTAND MY RIGHTS CONCERNING
"9OO' PAY.PER-CALL SERVICE CHARC ES
APPL]CANT SIGNATURE
DATE
BUSH-TELL, INC.
THE FOLLOWING INFORMATION IS BEING COLLECTED FOR FEDERA.L GOVERNMENT
REPORTING PURPOSES ONLY AND IS OPTIONAL
RACIAL/ETHNIC GROUP
CAUCASTAN
AFRICAN AMERICAN
HISPANIC
AMEzuCAN IND]AN OR ALASKA NATIVE
ASIAN OR PACIFIC ISLANDER
OTHER (PLEASE SPECIFY)
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