Name:
Email Address:
Contact Phone Number:
Social Security Number:
Date of Birth:
Service Address:
Current Employer:
Years Employed:
Position:
Employer's Address
Employer's Phone
Previous Employer (if current employer is less than one year):
Years Employed:
Position:
Name:
Social Security Number:
Date of Birth:
Employer:
Years Employed:
Please List other Adults with Access:
Current Telephone Company:
Current Telephone Number:
Current Address (if different from above):
Do you Own or Rent Property?
If you rent, Landlord's Name:
Landlord's Telephone Number:
Name:
Address:
Relative's Telephone Number:
Relationship:
Local Residential Rate
$15.95 - Does not include regulatory charges, taxes and other surcharges
Name:
Address:
Do you have a burglar alarm?
Phone Line Alarm is Connected To:
Telephone Number:
Directory Publishing:
Inside Wire Maintenance:
Voice Mail/Call Answer Service Click here for details.
Voice Mail Bronze Package
Voice Mail Silver Package
Voice Mail Gold Package
Voice Mail Platinum Package
Class Services/Custom Call Features:
Teen Service - $6.00 Automatic Call Back *66 - $4.50 Automatic Recall *69 - $ 4.50 Calling Number Delivery - $ 7.00 Dialable Number Delivery - $7.50 Calling Number/Name Delivery - $7.50 Dialable Number/Name Delivery - $8.00 Caller ID on Call Waiting - $1.50 Call Block *60 - $ 4.20 Distinctive Ringing/Call Waiting - $ 6.00 Selective Call Forwarding - $4.20 Avoid-A-Call - $4.20 Anonymous Caller Rejection - $1.00 Speed Calling 8 - $2.95 Speed Calling 30 - $3.50 Call Waiting - $ 2.95 Three Way Calling - $ 2.95 Call Forwarding - $2.95 Customer Choice Package - $ 9.95 Value Package - $ 9.95 Premium Package - $ 15.95
Brandenburg Telephone Long Distance
Choose a carrier:
Please freeze my long distance carrier so only I can change:
It is your responsibility to contact your carrier if choosing a provider other than Brandenburg Telephone Long Distance. These long distance charges will not appear on your local phone bill. We will make every effort to ensure that your telephone service is connected to the Long Distance Company you choose. In the event your service is inadvertently connected to a different company, we will assume liability only to the extent of connecting your chosen company at the earliest opportunity after you notify us.
DSL Customers are required to have an Ethernet card (NIC) installed prior to scheduled appointment.
Username (6-14 characters):
Password (4-8 characters):
If left blank and selecting any internet plan we will contact you for this information.
Choose a package:
16 local channels from Bowling Green, Elizabethtown, Lexington, Louisville, 7 Pay-Per-View access channels, C-Span, C-Span2, QVC, WGN, Local Weather and Home Shopping Network.
DV-Basic plus 58 premium TV channels and 45 music channels.
DV-Gold 166 channels including DV-Basic
Additional Packages:
Add this package to DV Basic or DV Deluxe to get 9 additional Sports Entertainment channels. TVG, Fuel, Fox Soccer, Fox College Sports Pacific, Central, Atlantic, Español, The Speed Channel & ESPNU.
Add an additional 24 channels including Speed, Boomerang, Discovery Kids, ESPNU, Noggin' and much more!
Add this package to DV Gold to get WAVE3, WLKY32, WHAS11 & FOX41 in HD.
Add this package to DV Gold to get HD Local package plus Discovery Channel, ESPN, ESPN2, HD Movies, HD Net, The Learning Channel, Discovery Theater, National Geographic, *Showtime & *Starz
*HD customers must subscribe to Showtime and/or Starz to receive these channels in Hi-Definition.
Channels
Price
$12.95
$14.95
Showtime with Showtime 2, Showtime Beyond, Showtime Extreme, Movie Channel, Showtime Showcase, Showtime Next, Showtime Family, Showtime Woman, Movie Channel, Movie Channel 2, and FLIX
$14.95
$11.95
$27.95
$27.95
$27.95
$27.95
$27.95
$27.95
$37.95
$37.95
$37.95
$37.95
$45.95
ESPN GAME PLAN(S), ADULT PROGRAMMING and DIGITAL VIDEO RECORDERS (DVR) are available upon request. Please contact our office for more details.
Automatic Bank Account Charge Authorization
Are you interested in automatic bank draft?
Please fill in your totals to estimate your bill.
$25.00 for telephone service
$15.00 for DV basic
$40.00 for DV Deluxe
$52.00 for DV Gold
DSL package
Dial-up package
Movie package
Additional Packages
Total
1 month charges for all services must be paid prior to installation.
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