Date of Order

Existing Qwest Phone #

Account #

Option 1 - I choose to keep Qwest phone number, $1.50 addtional per month cost

Option 2 - I choose to change to GAN phone # (only first three digits change)

Assigned Goldfield Access Network Phone #

Type of Service:

 Business    Residence

County

Name

Social Security No.

Date of Birth

Email Address

Street Address

City

State

Zip

Credit Reference 1)

Credit Reference 2)

Where Employed?

Have You Had Previous Service From Our Company? Yes     No

Previous Address Where You Had Service

Previous Phone Number Where You Had Service

Long Distance Carrier Choice:

In-State     Out-of-State

Are you requesting low-income assistance?

Yes     No

Contact for DSL Digital Subcriber Line

(High Speed internet option)

Yes     No

CHECK
TO
ORDER

SERVICES

COST

Resident Access

$9.95

($11.95 Renwick)

Resident access plan

$36.85

Residential Network Access Charge

$3.50

($4.50 Renwick)

Business Access

$19.95

Business Network Access Charge

$6.00

Voice Mail

$4.95

E911

$0.75

Service Order Charge

$17.50

Internet

$16.95

Internet Registration Fee

$10.00

Additional Email (each)

$5.00

CHECK
TO
ORDER

CUSTOM CALLING FEATURES

COST

Call Waiting

$2.50

Call Forwarding

$2.00

3-Way Calling

$2.00

All 3 Above Features

$5.00

Speed Dial 8

$1.00

Speed Dial 30

$2.00

Other

Other

Other

Other

Inside Wire Maintenance

$2.00

Keep existing Phone #

$1.50

Rollover Line

$2.00

CHECK
TO
ORDER

ENHANCED CALLING FEATURES

COST

Caller ID Blocking

N/C

Caller ID Suppression

$1.50

Customer Originated Trace (per trace)

$1.00

Distinctive Ring/Call Waiting

$1.50

Caller Number Delivery

$3.00

Caller Name Delivery

$1.50

Selective Call Acceptance

$1.50

Selective Call Forwarding

$1.50

Selective Call Rejection

$1.50

Warm Line

$1.50

Automatic Callback

$1.50

Automatic Recall

$1.50

3 Features (excl. Caller # Delivery)

$3.00

In making this application ,You agree to the rules and regulations of the Goldfield Access Network as set forth in the exchange 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 the Goldfield Access Network.

Applicant acknowledges their authorization for Goldfield Access Network to act as their communications representative/agent when dealing with Qwest. Applicant authorizes Goldfield Access Network to obtain information and/or copies of all network services and to order and manage all negotiations for the installation of telecommunications services for the above listed address and with respect to the above telephone number(s).