Service Application – Prentiss Connect

1. Contact information

First name *

Last name *

Full name (fills in automatically)

Email *

Primary phone *

Alternate phone

PCEPA Account # (if known)

2. Service address

Street address *

Apt

City *

State *

ZIP *

Is electric service in your name? *

3. Property information

Relationship to property *

Property ownerTenant or renter

Owner's name

Owner's phone

4. Requested service

Requested internet plan *

Estimated monthly charge

$—Phone service is taxed; internet data is not.

Paperless E-BillYour bill is emailed to the address above.

Phone service

No phone serviceNo chargeOne phone line$25.00/moTwo phone lines$45.00/moMore than two linesContact Customer Service

Good to knowEquipment, installation, and promo discounts may not be included.

6. Availability

When are you generally available for installation?Check all that apply.

Weekday morningsWeekday afternoonsNo preference

Your selection does not schedule or guarantee an appointment.

We'll contact you to arrange installation.

7. Additional information

How did you hear about us?

Comments

8. Acknowledgments *

I am 18 years of age or older. *

Yes No

I certify that I own the property where service is requested, or have the property owner's authorization to install and maintain the equipment necessary to provide service. *

Yes No

I certify that the information provided is accurate and authorize Prentiss Connect to contact me regarding this application and service at the address listed above. *

Yes No

I have reviewed and agree to the Prentiss Connect Service Agreement and General Terms and Conditions. *

Yes No

Submitting this application does not schedule an installation or guarantee service activation. A Prentiss Connect representative will contact you regarding the next steps.