Carrollton, Hamilton and Braymer SignUp Form Carrollton, Hamilton and Braymer SignUp Form It's time to build your Fiberhood! Sign up today to receive your ultimate Internet upgrade! Title of Primary Subscriber Mr.Ms.Mrs.Dr.Jr. First Name Last Name Date of Birth Daytime # Evening # Email (This email will be used for status updates on your Fiberhood's buildout) Service Address Service City Service State Service Zip Your Fiberhood * Is your Mailing address different from your Service address? Yes, they are different. No, they are not. Mailing Street Address Mailing City Mailing State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Mailing Zip Are you currently an existing Green Hills Communications customer? Yes I'm a current customer No, I am not a current customer Do you rent or own your residence? Rent Own Landlord Name Landlord Email Landlord Phone Number Internet Service Please select your Service Package * Package * Installation fee will be collected at start of service. Ultimate WiFi $15.00/mo (includes parental controls, device prioritization, virus/malware protection, and much more! One time $50 WiFi Analysis Fee) * Yes, I would like WiFi throughout my home I would like more information No, Thank You Total Care Plan (Maintenance Protection) $5.00/mo * Yes, I would like Total Care I would like more information No, Thank You Unlimited Local and Long Distance Phone Service Unlimited Local & Long Distance Phone $30.00/mo per line(Includes: Voicemail, Caller ID, Call Waiting, 3-Way Calling, Call Forwarding) No Thank You *Federal, state + local taxes + fees are not included, Long Distance includes calls made to lower 48 US States only, calls made to Hawaii, Alaska, US Territories or international countries will incur additional fees. Number of phone lines that need service 1 Phone Line2 Phone Lines Would you like to keep your current home phone number? Yes No Who is your current provider? * AT&TCenturyTelZitomediaSocket Telecom Current Phone Number Line 1 Current Phone Number Line 2 Would you like your number listed in the Green Hills Area Wide Directory? * Yes, I would like my number listed in the Green Hills DirectoryNo, I would not like my number listed How would you like your name listed? * UPS Battery - Notes: Phone service will NOT work in case of power outage without a UPS battery backup installed. This is not mandatory, but without a UPS battery backup installed, access to E911 will not work when power is out. * Yes, I would like more information No, Thank You *An uninterruptible power supply/backup battery that maintains power or up to 8 hours or 24 hours are available upon request. Bill Payment & Additional Options Bill Pay Options Email Bill (Auto-Pay / Mail in Payment) Paperbill and Mail in Payment How did you hear about Green Hills Communications? A Green Hills Fiber CustomerA FriendDirect Mail (letter/postcard)Door to Door SalespersonEmailEventFacebookLocalNewspaper AdNewspaper ArticleRadio AdWebsiteWeb AdYard sign To assist our construction crew, please list any fences or buried facilities (geothermal lines, sprinkler system, etc.) on your property that would not be found during a Missouri 1 Call locate. Any comments or additional information that we should be aware of? If you are human, leave this field blank. Submit
