SMBS
110 South Hwy 86
P.O. Box 1006
Lakefield, MN
877.655.7627
Customer Information: (Please print all information)
Rep _________________Business Name: Contact Name:
Contact Direct Phone: Contact Direct Email:
Service Address: PO Box:
City: State: Zip Code: County:
Business Daytime Number: After Hours Number:
Business General Email Address:
Billing Address (if different than above):
Small Business Packages
( ) Business Basic 1
- 1 Phone Line and 15/5 Mbps Internet Service; perfect for the small business Monthly
with less than 3 employees. Total Billable $ _______
- Phone line includes free calling to all SMBS and Windomnet customers. - $75.95/month
( ) Business Basic 2
- 2 Phone Lines and 15/5 Mbps Internet Service; designed for the small Monthly
business with 3-6 employees. Total Billable $ _______
- Phone lines include free calling to all SMBS and Windomnet customers. - $99.95/month
~ Telephone ~
Telephone Line Information:
Monthly( )Line 1 (507) ______-________ ( )Line 2 (507) ______-_________ ( )Line 3 (507) ______-________ Total Billable $ _______
( ) New Number Request ( ) New Number Request ( ) New number request --- ( ) Roll-over (Non-Published/Listed)+ ( ) Roll-over (Non-Published/Listed)+
( ) Published: Free* ( ) Published: Free* ( ) Published: Free*
( ) Non-Published**$2.50/mo ( ) Non-Published** $2.50/mo ( ) Non-Published** $2.50/mo
( ) Non-Listed*** $1.25/mo ( ) Non-Listed*** $1.25/mo ( ) Non-Listed*** $1.25/mo
* Free-Published: Name and number available in Directory and through Directory Assistance
** Non-Published: Name and number not available in Directory or given out through Directory Assistance *** Non-Listed: Name and number not available in Directory, but is available through Directory Assistance +Choose Line Hunting from Enhanced Calling Features below
Additional Phone Lines (Not included in Service Package)
- Each line includes toll-free calling to all SMBS and Windomnet customers.( ) Additional phone lines (in addition to package) Price #_Lines Monthly
$26.45 ___ Total Billable $ ______
Line 1 Directory Name Line 2 Directory Name Line 3 Directory Name
Listed as:____________________________ Listed as:____________________________ Listed as:____________________________
Address: ____________________________ Address: _____________________________ Address:_____________________________
( ) Omit address ( ) Omit address ( ) Omit address
Add’l Listing (.50/mo) Add’l Listing (.50/mo) Total Billable $ ______
Long Distance Plans (make choice for each line)
Line 1 Line 2 Line 3 Monthly ( ) Toll Free 800# : .12/minute (incoming only, no monthly fee) ( ) ( )
( ) Toll Free 800# Plus: .06/minute and $3.95 monthly charge (66 minute break-even point) ( ) ( ) Total Billable $______
( ) Basic Long Distance: .10/minute ( ) ( )
( ) Long Distance Plus: .06/minute and $1.99 monthly charge (50 minute break-even point) ( ) ( ) Total Billable $ ______ ( ) No Long Distance ( ) ( )
Enhanced Calling Features (á la carte)
Per billing period, per line charge.
Price Line 1 Line 2 Line 3 Monthly
Voice mail: $3.50 ( ) ( ) ( ) Total Billable $ ______ Caller ID: (name & number will show on Caller ID units) $3.00 ( ) ( ) ( ) Total Billable $ ______ Call waiting: (alerts you to an incoming call while on line) $2.50 ( ) ( ) ( ) Total Billable $ ______ Call forwarding: (transfer all incoming calls to another location) $2.50 ( ) ( ) ( ) Total Billable $ ______ Speed dialing: $2.50 ( ) ( ) ( ) Total Billable $ ______ Selective call rejection: $2.50 ( ) ( ) ( ) Total Billable $ ______ Busy call forward: $2.50 ( ) ( ) ( ) Total Billable $ ______ SIM ring: $4.00 ( ) ( ) ( ) Total Billable $ ______ Line Hunting: $2.95 ( ) ( ) ( ) Total Billable $ ______
~ Internet ~
( ) Business Internet 15M/5M $62.95
Total Billable $______( ) Static IP Address $5.00 each/month Qty. _____ Total Billable $______
- Increase your Internet speed to fit your business needs
( ) Deluxe – Add 10/5 to your Business Internet speed for $29.95/month Or…
( ) Express – Add 20/10 to your Business Internet speed for $59.90/month
Total Billable $______
Email Set-Up (up to 5 addresses)
Your login name: ______________________________________ Password:________________________________________ Your login name: ______________________________________ Password:________________________________________ Your login name: ______________________________________ Password:________________________________________ Your login name: ______________________________________ Password:________________________________________ Your login name: ______________________________________ Password:________________________________________
*Your login name(s) will establish your e-mail address(es) to use in all your Internet correspondence. Your login name(s) can contain a combination of lower case letters and/or numbers.
Some examples of login names are [email protected], [email protected], and [email protected]. Your password should be at least 6 characters in length, and should contain both numbers & letters.
~ Video Pricing ~
Video Packages Monthly
( ) Basic Video $29.50 Our economic package offering 24 Channels, including local network affiliates Total Billable $ ______
( )Expanded Basic $63.90 A diversified package offering 74 Channels, including local network affiliates, Total Billable $ ______ Video super stations, popular sports, news information, and family programming.
( )Digital Basic $86.60 An Expanded package including Basic, Expanded Basic, 58 additional Total Billable $ ______
channels, and 30 music channels
F
irst set-top box is free with digital package; additional boxes are available for $7.95/month
Add-ons for any digital video package*: Monthly
( ) HD Package $12.95 Total Billable $ ______
( ) HBO Package $16.95 Total Billable $ ______
( ) Showtime/TMC/Flix $14.95 Total Billable $ ______
( ) Starz/Encore $14.95 Total Billable $ ______ Total Billable $ ______
* Digital Packages require a set-top box. First set-top box will be provided at no charge.
Additional Equipment Rentals: Set-top box @ $0.00 _____ (w/qualifying package) Monthly
Add’l set-top boxes (HD capable) $7.95/mo. - Qty ___ HD DVR boxes $14.95/mo. - Qty ___ Total Billable $ ______ (DVR box does not qualify for free box)
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~ Additional Information ~
Standard/New Outlet Installation
New outlets can be installed within the primary business location at the customer’s request. The cost per outlet may vary. Due to the nature of inside wiring and the uniqueness of each location, it may not be possible to estimate the cost for installation. The charge for installation of the NEW outlets will be on a “time and materials” basis. Cost of materials will be determined at time of installation. Price shown below is for “standard” installation of new jacks.
Routers for wireless internet usage can be purchased through your choice of retailer.
One Time Charge Phone Jacks ( ) Additional new jacks $55.00 - Qty installed ____ Total Billable $ ______
Video: ( ) Install NEW outlets $55.00 Anticipated # of new outlets ____ - Qty installed ____ Total Billable $ ______
VCR's/Stereo/Entertainment Systems/Game Consoles
SMBS will not connect or provide the labor necessary to install these items. A customer that chooses to have these systems or similar ones connected is responsible for any parts, wiring, and labor necessary. SMBS will not provide any parts or wiring for the connection of electronics.
4/15/15
~ Service Summary ~
Service Package
Quantity Total ( ) $75.95/mo. Business Basic 1 $ _______
( ) $99.95/mo. Business Basic 2 $ _______
( ) $62.95/mo. Business 15/5 Internet $ _______
( ) $26.45/mo. Additional Phone Lines _______ $ _______
( ) $29.95/mo. Deluxe or… ( ) $59.90/mo. Express $ _______ Additional a’ la carte features:
Phone $ _______ Internet $ _______
Video $ _______
* Above rates are monthly charges. Access fees and taxes will be added to monthly billings.
Total Estimated Monthly Charges* $ _____________
One-Time Charges $ _____________
* Additional taxes and Franchise Fees may apply. Total monthly charges will vary with usage of long distance service, etc.
Letter of Agency
(Required for phone service, if porting number or numbers from another provider) I authorize Southwest Minnesota Broadband Service (SMBS) to act on my behalf as my agent to*: ___ Transfer my local telephone service from _______________ to SMBS.___ Transfer my long distance service for calls within the 507 Area Code from _______________ to SMBS. ___ Transfer my long distance service for calls outside the 507 Area Code from _______________ to SMBS.
Current phone service provider is: ____ Qwest (Century Link) ____ Century Tel (Century Link) _____ Frontier ________ Other Long distance provider if not SMBS _________________
Name (Please Print) ______________________________________________________________________________________________ Phone number to be ported ________________________________________________________________________________________ Address ____________________________________________________________ City: ______________________________________ Signature _________________________________________________ Date ________________________________________________
* Authorization: We will contact your current phone provider on your behalf to transfer your service to SMBS.
This makes changing to SMBS convenient since we make all the calls necessary for you to coordinate the phone service transfer with your current provider.
Security
Required Security Password – CPNI – Customer Proprietary Network Information – choose a password up to 15 characters
Suggestions: Mother’s maiden name, favorite pet, favorite color __________________________________________________________ Password Hint (we give to you should you forget what you told us) ________________________________________________________
Acceptance
I, the undersigned, request a Southwest Minnesota Broadband Account. I have received, read and agree to the Southwest Minnesota Broadband Service rates and request the services that I have identified in this service order form. I grant an easement and permission to SMBS to bury a service line onto my property for the express purpose of service delivery to solely my property.*
Signed___________________________________________________(Must be 18 years or older) Date__________________________
(Must be signed by subscriber or co-subscriber listed above)
*If business owner is not the owner of the property, landowner must sign drop permission slip.
