Customer Application

Customer Application

Customer Information

Account Owner's Name, Primary
Account Owner's Name, Primary
First
Last
Additional Account User, Secondary (optional)
Additional Account User, Secondary (optional)
First
Last
Service Address *
Service Address
City
State/Province
Zip/Postal
Have you had service to this address previously?
Mailing Address, if different from service address
Mailing Address, if different from service address
City
State/Province
Zip/Postal
Are you interested in applying for Wisconsin Lifeline Program or ACP discount?
Who referred you?
Who referred you?
First
Last

Internet

TV

Phone

Bundles

Additional Support

Platinum Support, $6.95
Repair protection for phone/data jacks and inside wiring, as well as, in-home support for on-hardware related issues. Note: Internet customers who opt out of Router/Managed Wi-Fi do not qualify for Platinum Support.
Backup Battery
Provides power to voice service during a power outage.
Please select your billing and payment preferences:

Almost done! We just need a little paperwork.

Before we can process your application, we will need you to complete a few forms. You can upload them to this application.
W-9 Tax Form (Required) Permission to Bury Fiber (Required for new construction, please print to draw site survey) Autopay Form (Optional) Long Distance (If taking phone)

Maximum file size: 52.43MB

Bill Estimate

This is an estimate of your monthly charges before taxes and fees. Month-to-month and a la carte product prices subject to change. Prices do not include applicable taxes or surcharges. A charge of up to $99.00 will be billed upon re-activation of service(s). A charge of $50 will be charged for new installation of service(s). Billing will begin upon installation completion. Internet speeds reflect offerings up to the level indicated, and may be affected by various network or environmental issues. By signing below you agree to comply with the Terms & Conditions of internet service if applicable (Terms & Conditions available at www.MarquetteAdams.com). Vacation rates for telephone service-$10 per month. Restrictions apply.
I have read and agree to the Universal Service Agreement.
Click here to view the Universal Service Agreement
I give Marquette Adams Telephone Cooperative permission to bury a fiber connection and/or install service to my home.
I authorize that this form is completed correctly, and that all services be activated upon installation.