Name

First Name

Last Name

Physical 911 Address - Please include a copy of your 911 Verification Form from Blackfeet Dispatch

Address, City, State & Zip

Alternate/Common Physical Address - Example: 1210 Low Rent

Billing Address (if different than Service Address)

Address, City, State & Zip

Date of Birth

SSN/TIN

Current Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Current Employer Name & Number

Do you want to include your name in the directory? If no, there is a $5 charge.

Yes

Are you renting?

Yes

Landlord's Name (if renting)

Date Service Requested (Allow 7-10 business days)

Residential Internet

10/3Mb Bronze - $49.95

15/5Mb Silver - $58.95

25/10Mb Gold - $74.95

50/20Mb Platinum - $94.95

100/50Mb Diamond - $114.95

Do you want Bark Parental Controls - $12

Yes

Residential Phone

Residential Phone - $22.50

Long Distance Service Options

Residential only - Businesses ask for options

600 Minutes - $25.00/mo

15¢/minute Flat Rate

Home Front Package - 8¢/minute + $7.95/mo

All prices shown are monthly, with the exception of installation. Prices do not include regulatory fees, surcharges and/or taxes. Speeds are not guaranteed and vary by location; actual speed depends on a variety of factors. All services may not be available in all areas. $10/mo discount given when customer has both Internet & Phone services. Must have speeds up to 25Mb to qualify for Lifeline & ACP. Hardware remains property of Siyeh Communications. A $250 equipment fee will be charged if equipment is not returned; customer is responsible for lost, stolen or damaged equipment.

Customer Proprietary Network Information (CPNI)

CPNI allows us to discuss account information only with the person(s) listed on the account. We will confirm the identity of inbound callers by asking them to provide the last 4 digits of their social security number. We cannot share certain call detail information, on an inbound call, regardless of authentication. That information will be mailed, given by a returned call or hand delivered. In addition, customer is providing express, written approval to communicate via the designated email address in connection with service and account inquiries made by the account owner or designated account users. This approval includes responses to inquiries related to the customer’s services generally and specifically to inquiries concerning call detail information and account information including CPNI. Authorized contacts can discuss account information and make changes to your account. Authorized contacts will not be responsible for payment of your account. If you DO want to add authorized contacts, please list them below.

Your favorite Food

Name of favorite pet

What was your first car?

Passcode (list phrase or 4 digit PIN Number)

Assistance Programs

Financial assistance is available for eligible Iowans to help them afford basic telephone and/or broadband service thru Lifeline & the Affordable Connectivity Program.

I'm interested in learning more about Lifeline & ACP

Automatic Payments - I'm interested in setting up Automatic Payments from a Checking or Savings Account

For security reasons, we require a physical signature and voided check. We will contact you to set this service up.

Yes, I'm interested in Electronic Payments. Please contact me.

No, I'm not interested in Electronic Payments at this time.

Customer Acknowledgement (Signature Required - Please Type Your Name)

In making this application, the undersigned agrees to the rules, regulations and terms of Siyeh Communications as set forth in the related documents found on the Forms, Terms & Policies page (link in footer). Copies of documents also available upon request. This application becomes a contract when accepted by Siyeh Communications.

Thank you for your application. A Siyeh Representative will be on contact to schedule your installation and answer any questions you may have.

Residential Application for Service

Contact

Office Location

Quick Links