Business Telephone Service Application Click Here to Download Application Date Service Desired Month Day Year Name of Business Owner/President FEIN Federal Employer Identification NumberType Corporation Partnership Proprietorship Government WI State Tax Exempt? No Yes Please attach exemption certificateMax. file size: 256 MB.Street Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residential Address & Phone Numbers of Principal Owner or PartnersName Email Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact PhoneCurrent PhoneLifeline/Linkup qualified? Yes No Directory Listing Print Listing for Directory - No Charge Additional Listing - $2.00/month Unlisted (Not printed but available through directory assistance) - $1.00/month Unpublished (Not printed or available through directory assistance) - $2.00/month Listing for Directory Additional Listing Local Telephone Service Installation is $67.00 per line plus 1st month local service $34.00 in advance (Total $101.00) Basic Residential service in 349 calling area is approximately $34.00/month Extended Community Calling (ECC) is billed at $.05/minute Local Telephone Service Caller I.D/Number & Name $4.75 Caller I.D/Number $1.25 Call Forwarding $1.25 Busy Call Forwarding $1.25 3 Way Calling $1.25 Automatic Payment - No charge Rollover - No charge Caller I.D. Number $2.50 Caller I.D. Name & Number $4.75 Caller I.D. Number/Call Waiting $3.50 Caller I.D. Name & Number/Call Waiting $5.75 Selective Call Acceptance $1.50 Selective Call Rejection $1.50 Voice Mail/Basic $2.50 Voice Mail/Enhanced $3.50 Additional Lines (Same cost as first) Calling Exceptions No long distance ECC calling only 900 block Third party call block Collect call block Pic Freeze Long Distance - Interlata Long Distance Carrier Siren Communications AT&T MCI US Sprint Other Long Distance - Intralata Long Distance Carrier Siren Communications AT&T MCI US Sprint Other Notification upon application for service: The Public service Commission of Wisconsin’s Administration code Chapter 165.052(5), states: “A utility shall not disconnect any RESIDENTIAL service without notifying the County Department of Health and Social Services at least 5 calendar days prior to the scheduled disconnection IF THE CUSTOMER OR A RESPONSIBLE PERSON HAS MADE A WRITTEN REQUEST FOR THIS PROCEDURE TO THE UTILITY.” We are required to inform you of this right. In making this application the undersigned agrees to the rules and regulations of Siren Telephone Company, Inc. Set forth in the Telecom tariff, and to any general changes in rules, or rates for the service furnished under this application. This application becomes a contract when accepted in writing by Siren Telephone Company, Inc. If applicant/s credit rating is found to be not satisfactory a cash deposit will be required. I certify that all the information provided is correct to the best of my knowledge and that any false statement provided is grounds for Siren Telephone to discontinue telephone service.Applicant Signature Date Month Day Year Co-Applicant Signature Date Month Day Year CAPTCHA
