WildBlue Internet Application
CUSTOMER INFORMATION
 Are you currently a Northwest Internet Customer? Yes No           
 If "yes", do you want to disconnect your dial-up account after wireless installation? Yes No

*Your current email address:

 *Name:
 		 *Street Address:
  *City:
  *State:         *Zip:
 Billing Name (if different):
  Mailing Address:
  City:
  State:         Zip:
 *Home Phone with Area Code:
 Work Phone with Area Code:
 FAX (With Area Code):
 County:
 Your Social Security Number:                   Your Federal Tax ID Number:                    *Your Mother's Maiden Name (For Security):      
How Did You Hear About WildBlue?
PRIMARY E-MAIL ADDRESS
 *1st Requested Choice - no punctuation                   *2nd Requested Choice
 (Or current NCN e-mail address):                                (if 1st isn't available):
@ncn.net               @ncn.net		 E-Mail Address Note:  Sixteen characters or less.  If yours is unacceptable or unavailable, one will be chosen for you.
*Denotes Required Fields
FILTERING OPTIONS
Your e-mail accounts include free Postini® spam e-mail filtering.
Would you like this service activated on your e-mail accounts? Yes    No

Click here for more information regarding these options!

Postini® Virus Filtering included with every account
WIRELESS PLANS
  WildBlue Residential Value Pak 512k - $49.95/month
Plus $175 Installation & $299 Equipment Fee
Includes 5 email addresses, virus and spam email filtering
  WildBlue Select Pak 1.0mb - $69.95/month
Plus $175 Installation & $299 Equipment Fee
Includes 5 email addresses, virus and spam email filtering
  WildBlue Pro Pak 1.5mb - $79.95/month
Plus $175 Installation & $299 Equipment Fee
Includes 10 email addresses, virus and spam email filtering

*Speeds up to 512k, 1.0 mb, or 1.5 mb dependent on network activity.
WildBlue requires a Network Interface Card (NIC).  If your computer does not have a NIC card, one can be installed for $35.00 at time of wireless installation. Not all locations can receive WildBlue. There will be a no-charge site survey to make sure your location is WildBlue-ready.
STANDARD INSTALLATION TERMS
*Standard installation includes installation of satellite equipment and connection to one computer. Installations that require extraordinary time or resources will be billed an additional charge. Customer will be informed of charges prior to installation. Customers requiring connection of two or more computers will be charged $75 per hour plus additional materials.
ADDITIONAL E-MAIL ADDRESSES
Value & Select accounts receive 5 e-mail addresses and Pro accounts receive 10 e-mail addresses.  You may request additional addresses for $3.00/month for Residential and $5.00/month for Business accounts.   In addition, you can activate Postini spam filtering for $3.00/month per e-mail address.
 1st Additional E-Mail Address (no punctuation):
@ncn.net
Include spam Filtering

 2nd Additional E-Mail Address (no punctuation):
@ncn.net
Include spam Filtering
 3rd Additional E-Mail Address (no punctuation):
@ncn.net
Include spam Filtering

 4th Additional E-Mail Address (no punctuation):
@ncn.net
Include spam Filtering
Note: 16 characters or less.  If your choice is unacceptable or unavailable, one will be chosen for you.

COMPUTER SYSTEM
  MINIMUM REQUIREMENTS: WE RECOMMEND:
Memory
PC CPU
PC OS
Mac CPU
Mac OS 		128 MB or More
Pentium or AMD K6-2
Windows 98 SE
Power PC
System 9		 128 MB or More
Pentium III or AMD K7
Windows 2000 or XP
G3
System 9 or Higher
SALES INFORMATION

Sales Agent or "Buddy"
Click here for more info about our Recruit-A-Friend Program!
Buddy credits will not be paid on applications taken to      
Authorized Northwest Sales Agents.                 
DID YOU KNOW Northwest Communications OFFERS ALL OF THESE PRODUCTS & SERVICES?
 Please check items you are interested in or would like more information about:
Dial-up Internet
Companion Dial-up for When I Travel
Personal 800 Dial-up
Computers or Servers
Firewall
Networking
 Video Conferencing
Web Page Hosting
Web Page Design
Personal Web Site
Spam & Virus Filtering
Content Filtering		 Additional Emails
IP Telephone System
Paging
Dedicated Circuit
Recruit-A-Friend/Buddy Program
Other
CUSTOMER SERVICE AGREEMENT
I understand and acknowledge that continued use of Northwest's Services constitutes acceptance of the Terms of Service, Acceptable Use Policy and other important policies posted on Northwest's Website www.ncn.net. WildBlue Residential Agreement, Business Agreement, Product Warranty, Fair Access Policy. I agree it is my responsibility to read these policies and comply fully with their terms. I further understand the policies and pricing of Northwest's Services may change from time to time upon 30 days notice. The Service is provided on an "AS IS" and "AS AVAILABLE" BASIS WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF TITLE OR IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.  MINIMUM 30 DAY CHARGE FOR SERVICE. If service is cancelled, customer agrees to return all equipment in working order within 10 business days or pay an equipment charge of $200.
PAYMENT INFORMATION
Please bill me monthly via:
Mail      Debit my checking account automatically      Charge to my credit card

For automatic bank deduct and credit card payments, click here to download the form to mail. Credit Card | Bank Deduct
Please complete the form and mail it to our office at 844 Wood St., Havelock, IA 50546.
I accept and understand the Customer Service Agreement and the Standard Installation Terms.
      I further acknowledge that I agree to a one-year contract for service, if service is available to me.

   If you do not agree, click this button to exit without submitting this application: