Customer Sign-Up Form

Service Type

Phone

Internet

Package

Additional

Information

Choose Residential or Business Service?

Click Here

to Begin

Click Here

to Begin

Downloadable:

• Residential Sign-Up Form
• Residential Fiber Sign-Up Form
• Business Fiber Sign-Up Form

Service Type

Phone

Internet

Package

Additional

Information

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TV Services

Do you need TV?

Yes No

Service Type

Phone

Internet

Package

Additional

Information

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Phone Services

Do you need Phone?

Yes No

Service Type

Phone

Internet

Package

Additional

Information

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Internet Services

Do you need Internet?

Fiber Optic * High-Speed No

What is Fiber Optic*?

Fiber optic cable uses pulses of light traveling through thin strands of glass or plastic to transmit data at high speeds over long distances. Fiber optic internet speeds are about 20 times faster than regular cable.

* Not available in all areas. Check to see if available for you, contact us.

Service Type

Phone

Internet

Package

Additional

Information

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Internet Services

Type of Internet?

Fiber Optic * High-Speed

What is Fiber Optic*?

* Not available in all areas. Check to see if available for you, contact us.

Service Type

Phone

Internet

Package

Additional

Information

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Choose a Package

Service Type

Phone

Internet

Package

Additional

Information

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Movie Channels

Would you like movie channels?

Yes No

Movie Channels

Choose Channels

Choose Multiple

Starz / Encore

$12.95 / mo.

Premium Movie Channel

Showtime / TMC

$15.95 / mo.

Premium Movie Channel

Cinemax

$15.95 / mo.

Premium Movie Channel

HBO

$19.95 / mo.

Premium Movie Channel

Hispanic

$9.95 / mo.

Premium Channel

Done

Service Type

Phone

Internet

Package

Additional

Information

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TV Options

Choose TV Options and click Done

TV Options

How Many TVs?
How Many TVs?
Which rooms are the TV's located?
Is your basement ceiling drywall, drop tile, or open?

Set Top Box
A Set Top Box is required for each Television Set. No equipment is required to be purchased. Choose the Set Top Box type and number needed to rent each month.
Standard Set Top Box? A Standard Set Top Box (STB), or Cloud DVR STB, is necessary to receive broadcast signals for cable TV.		$5.00 / mo.
Cloud DVR Set Top Box? A Cloud Digital Video Recorder (DVR) Set Top Box (STB) stores recordings on a service provider's servers (Cloud) instead of a home device.		$5.00 / mo.
Jack Install (First TV Free)? If you need assistance installing a TV jack to receive content.		$75.00

Done

Service Type

Phone

Internet

Package

Additional

Information

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Internet Options

Internet Services Options

Modem / Router
	Modem/Router Rental (per mo.) A modem router is a single unit that combines the functions of a modem and a router. The modem component connects your home to the internet .	$10.00
	Modem/Router (1-time) A modem router is a single unit that combines the functions of a modem and a router. The modem component connects your home to the internet .	$99.00
	Modem/Router (Fiber) A modem router is a single unit that combines the functions of a modem and a router. The modem component connects your home to the internet .	FREE

Wireless Information
	WiFi Network Name: WiFi Password: (Required - 8 alphanumeric.)

Static IP Address
Static IP Address? Static Internet Protocol (IP) Address is an assigned numerical identifier for a device on a network on a static (fixed) basis, that doesn't change, allowing it to be used for hosting and remote access solutions.		$10.00

Done

Service Type

Phone

Internet

Package

Additional

Information

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Telephone Options

Choose Telephone Options and click Done

Telephone Options

Calling Features
	A $20 Install Fee Applies for Phone Services
	Call Forward
	Call Waiting
	Caller ID (Number Only)
	Calling Name (Name Only)
	Voicemail

Pierce Long Distance Plan*
	Combine multiple Long Distance Plans to get the perfect package.
	Pierce Simple 50	$6.00
	Pierce Simple 100	$10.00
	Pierce Simple 200	$18.00
	Pierce Simple 500	$40.00
	Toll Free Number	7¢/min.
*All rates do not include Connection Fee, Tax, Universal Service, FCC charges, E911 charges, DSL on-time charges or equipment, or other toll calls. Rates are figured at 10 cents/min and 15 cents/min in-state after plan minutes.

Done

Service Type

Phone

Internet

Package

Additional

Information

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Contract Options

Choose Billing Options and click Done

Billing Options

Contract
	24-Month Minimum Service Contract	FREE
	No Contract	$95.00

Credit
	Automatic PaymentsA $2 monthly credit applies to your account if your account is Paperless and Automatic Payments are set.	$2 credit!A $2 monthly credit applies to your account if your account is Paperless and Automatic Payments are set.
	Paperless BillingA $2 monthly credit applies to your account if your account is Paperless and Automatic Payments are set.

Inside Wire Maintanence
	Inside Wire Maintenance You are responsible for the repair and maintenance for your inside wiring. Without the plan, a minimum fee of $45 plus materials applies if a repair is needed. This plan does not cover trouble with customer owned equipment.	$2.00 / mo.

Check out our PTC Mobile Nationwide Cellular Service
	Yes, please contact me about a PTC Mobile Plan.

Done

Service Type

Phone

Internet

Package

Additional

Information

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Information

Date Ready for Service:

First Name:

Last Name:

Address:

City:

State:

Zip:

Phone:

E-mail:

Agreement

I AGREE to release this information for office use only for this preliminary signup form from Pierce Telephone Company, Inc. You will be contacted by a representative for further details and get you started with PTC services. You will need these items to complete your application:

Requirements:

Must be at least 18 years old.
Text or email Drivers License or Photo ID.
Social Security Number.
Deposit.

Pierce Telephone Co., Inc.
112 S. 5th St.
P.O. Box 113
Pierce, NE 68767
888-329-6225

Submit

Customer Sign-Up Form

Choose Residential or Business Service?

Do you need TV?

Do you need Phone?

Do you need Internet?

What is Fiber Optic*?

Type of Internet?

What is Fiber Optic*?

Choose a Package

Would you like movie channels?

Choose Channels

Choose Multiple

$12.95 / mo.

$15.95 / mo.

$15.95 / mo.

$19.95 / mo.

$9.95 / mo.

Choose TV Options and click Done

TV Options

How Many TVs?

Set Top Box

Internet Services Options

Modem / Router

Wireless Information

Static IP Address

Choose Telephone Options and click Done

Telephone Options

Calling Features

Pierce Long Distance Plan*

Choose Billing Options and click Done

Billing Options

Contract

Credit

Inside Wire Maintanence

Check out our PTC Mobile Nationwide Cellular Service

Information

Agreement

Requirements: