Home Phone Service

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Service Order Request Form

Service Request
1. Type of Service

New Service - I don't currently have working service at this address (This government assistance service is available on the primary line ONLY)
Convert my Existing Number (must have working or suspended service and provide Current Home Phone number below. Also, we cannot convert your existing number if it is a cable company phone line or a VOIP service.)

2. Prior Working Service

If you have had working service at this address within the last 60 days, please provide the following:

Service Provider Name (i.e. AT&T)
Prior phone number     (###-###-####)

3. Choose a plan (Activation for each plan is $30, billed after service is active.)
Important plan pricing and billing information. Please read carefully.

A. Bronze, $32.49* (before discounts) + taxes/fees. Basic service, 100 Minutes Long Distance.
B. Silver, $37.49* (before discounts) + taxes/fees. Basic Service with Call Waiting, Caller ID, 100 Minutes of Long Distance.
C. Gold, $40.49* (before discounts) + taxes/fees. Basic Service with Call Waiting, Caller ID, Call Return, 3 Way Calling, Call Forwarding, Call Blocker, Priority Call, Speed Calling, 100 Minutes Long Distance.

* Each plan will receive a $16.00/mo discount once Lifeline eligibility is confirmed with the Texas LIDA.

* To get an additional $8/mo discount, please call customer service once your service is active and request to be enrolled in auto-pay.


Customer Information
First Name * Last Name *
Home Address *
Address 2 (Apt etc)
City   * State * Zip  *
  (We provide service in the AT&T - SBC area only)  
Last 4 Digits of SSN *    
Date of Birth *  (mm/dd/yyyy)    
Current Home Phone   (###-###-####)    
Contact Phone # *  (###-###-####)    
Account Password *  Supply a password for making changes to your account
eMail Address   *Required fields

Eligibility for Lifeline. Choose all programs you currently participate in.(must pick at least one)
Food Stamps
Medicaid
Supplemental Security Income (SSI)
Health Benefit Coverage under Child Health Plan (CHIP)
Low Income Home Energy Assistance Plan (LIHEAP)
Federal Public Housing Assistance - Section 8 (FPHA)
Income at or below 150% of Federal poverty level
   
Please read and certify the following statements by checking the boxes below:
* I authorize New Talk to be my local and long distance carrier for the number listed above (or to be issued). I also understand that I will be billed for my telephone service by New Talk. (In order for us to provide you with phone service, this check box is required)

To the best of my knowledge, no one in my household is receiving a Lifeline-supported service from any other provider. (Only one Lifeline benefit is available per household. If you do NOT check this box you will not be eligible for the Lifeline discount.)