Genuine Telecom
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Online Application

Apply on-lineThis Genuine Telecom Application Form is available in the Adobe® Acrobat format. To view a document in this format, you must have the free Adobe Acrobat Reader installed on your computer. If you do not have Acrobat Reader, it is downloadable for free directly from Adobe's web site. Print and Mail Application (20 K file)Acrobat File Get Acrobat Reader

 More About Us
Why You Should Join
Phone Services
Calling Cards, Prepaid Phone Cards
High-Speed InternetDigitsl Cable TV
Mission Statement
Apply Online
Home
Or, you can complete and submit the online form below.
Physical location where you are requesting telephone service * Indicates required information.

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* Type of Service:
 Business Residence       * Date Requesting Service (MM/DD/YY):
* Billing Name:    
* Telephone Number:    
* Billing Address:    
* Directory/911 Name:    
* Directory/911 Address:    
* City:     * State: * Zip Code:
* County:    
* Email Address:    
* Do you own or rent your home?     Own Rent
Landlord's Name:    
Extra Listing:    
Previous Resident:    
* Current Billing Plan:     Unlimited Value Pk Econo Pk
Close Neighbor:    
* Do you wish to change plans?:     Unlimited Value Pk Econo Pk No Change
* Long distance (toll) carriers - YOU MUST CHOOSE A TOLL CARRIER
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Intralata (within 608 area code) list carrier:
Interlata (outside 608 area code) list carrier:
* Pic Freeze: Intralata ONLYInterlata ONLYALL Long DistanceLOCAL
* Wire Maintenance ($3/mo): Yes No
Optional Custom Calling Services
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List the custom calling services, if any, you wish to add now. There will be a service charge fee to add services after conversion (see choices on information sheet):
* Keep existing custom calling services that I currently have: Yes No
* 900 Number Blocking (You must choose one!)
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Yes, block all 900 calls from my phone:
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No, do not block 900 calls from my phone. I will be responsible for all 900 calls and charges.

Applicant Information
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* Previous Address:
* Previous Telephone #:
Previous Telephone Company:
* Employer: Other Source of Income:
* Social Security #: * Driver's Licence #:
* Name and Address of Bank:

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Other Adult Living in Household
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Name:
Employer:
Social Security #: Driver's Licence #:
In completing this application for telephone service, I authorize Genuine Telecom to obtain customer service records from my local telephone service provider and to switch my local service to Genuine Telecom. I also agree to pay the established rates for all services and/or equipment. In addition, I agree to the rules and regulations of Genuine Telecom as set forth in the exchange tariff. I further certify that I am over 18 years of age.
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* Type Full Name:
* Date:

| About Us | Why Should You Join? | Phone Services | Calling Cards & Prepaid Phone Cards |
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Genuine Telecom
PO Box 409
Richland Center, WI 53581
608-647-2345 or:
888-454-5114
608-647-4265 (Fax)

Email: info@genuinetel.com
Copyright © 2002 - 2008 Genuine Telecom. Last Revised May 5, 2006.
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