APPLICATION FOR INTERNET, TELEVISION & VOICE SERVICE

1. Terms of Service:

The communications services and ancillary equipment you order and receive from Griswold Communications are subject to our General Terms and Conditions of Service and Service-specific Terms and Conditions of Service. By ordering and accepting service, you agree to adhere to these terms and conditions, including any modifications to such terms and conditions as we may communicate to you from time to time. If you fail to comply with our terms and conditions, your service may be suspended or disconnected. Griswold Communications is an equal opportunity provider. Information is securely transmitted and stored.

2. Subscriber Name(s) & Social Security Number:

Primary Applicants Name:

Primary Applicants Social Security #:

Co-Applicants Name:

Co-Applicants Social Security #:

_{Both the Primary Applicant and Co-applicant are responsible to pay for all rates and charges for all products and services.}

Authorized Users to Add to Account:

Authorized Users are optional. Adding authorized users does not mean their name will show up on the bill, but only that the company is authorized to discuss service and account questions with these individuals. Authorized users can inquire about the account, but can not make changes to the account.

Legal Name(s)

The Primary Applicant will be established as the account owner. Any Co-Applicant(s) or Authorized User(s) may be removed from the account or account access at any time by written direction provided by the Primary Applicant.

3. Service Address

Address

Address Line 2

City

State

Zip

4. Mailing Address

Mailing address is the same as service address

Address

Address Line 2

City

State

Zip

5. Contact

Primary applicant phone number

Co-applicant phone number

Please check one:

Paper

eBill

6. Cooperative Organization - Stock Purchase

Being a cooperative the purchase of a share of stock for $25.00 is recommended. The ownership of the share of stock is evidenced by the name(s) listed on the stock. The stock should be made out to subscriber(s) listed above.

Being a cooperative, the amount of margins after expenses are allocated to the patrons each year. The patron (subscriber), in order to receive the payment of margins, should inform the cooperative of any change in address. When the cooperative pays dividends, the dividends will be sent to the address on file. Upon receiving a returned check we will try to locate the patron for payment. However, if such person cannot be located, such person agrees to donate such dividend payment for the benefit of the cooperative. By signing you agree to be responsible for prompt monthly payments. In order to maintain our mailing address, please give the following information -

Name and Address of a close relative (other than spouse):

_{At the discretion of the telephone company, dividends could be applied in full or in part to the customers account if the customer has been late in payments 6 or more times and has been disconnected at least once in the past year.}

7. Email Address of Record:

Upon establishment of service, your mailing address of record is the billing address for your account. If you wish to establish an electronic address of record, you must provide us written instruction of the email address you wish to designate as your electronic address of record. If you wish to establish an electronic address of record, please complete this section, including checking one or more of the boxes, which will serve as your written instructions. The designation of an electronic address of record for any of the purposes below is optional. If you have not selected eBill, but you choose to establish an electronic address of record, it will not change the billing address for your account. You may revoke any or all of these permissions at any time by written notice to the cooperative.

Email Address of Record:

If you need an email address, fill in a preferred username. New (@netins.net)

I hereby designate the above email address as my billing address for eBill.

I hereby consent and grant the company express permission to use the above email address as the electronic address of record in connection with service and/or account inquiries made by an account owner or designated account user(s). This includes without limitation inquiries relating to customer proprietary network information (CPNI), as defined under federal law. This designation will be effective 30 days following the in-service date.

To the maximum extent permitted by law, I hereby consent and grant the company express permission to use the above email address as the electronic address of record in connection with any account or service notice required under any state or federal law or regulation governing communications services provided by the cooperative.

To the maximum extent permitted by law, I hereby consent and grant the company permission to use the above email address as the electronic address of record in connection with any notice or other communication sent by the company and relating to my membership in the cooperative, including without limitation notices of annual or special meetings of the members of the cooperative.

Establishment of Telephone Service:

8. Telephone Bill -Cycle and Payment Due Date

Monthly bills are mailed out on the 10th of the month and are due upon receipt. The bills indicate a payment date no later than the 30th of the month (with the exception of February). Payment not received on or before the 30th of the month is subject to disconnection. Local service is billed in advance. Tolls are billed in arrears. For example a June 10th billing would include the toll calls for May 1 through May 31.

9. Lifeline Assistance is available for qualifying individuals.

Please ask for a Lifeline Assistance form if applicable.

10. Available Telephone Service and Options (ask about pricing):

If published, please indicate how to appear in Telephone Directory:

11. PIC Freeze:

Under FCC rules, Griswold Communications is not allowed to verify customer requests to change long distance carriers. A PIC Freeze ensures that your long distance carrier will not be changed without your knowledge by requiring you to notify the company of any carrier change in advance. Please note, a valid long distance carrier change will be rejected if you do not contact the company. Requests for long distance carrier changes require a service fee.

YES - I wish to add a PIC Freeze to my selection of long distance carriers. By selecting a PIC Freeze option and signing below, I am providing Griswold Communications with express, written approval to add a PIC Freeze to my account at no charge.

If Yes, please choose ONE of the three options below:

Intralata and interlata long distance carriers

Intralata long distance carrier only

Interlata long distance carrier only

_{Once a PIC Freeze is in place, you must personally contact Griswold Communications by phone or in writing to authorize a change in my long distance carrier.}

NVT Option:

NVT $0.14/min

NVT $0.10/min $3.95/month

blueSURGE Television Service

blueSURGE television $121.95

Economy blueSURGE television $39.95

HBO Movie Pkg. $11.99

Cinemax Movie Pkg. $11.99

Starz/Encore Movie Pkg. $11.99

Set Top Box $5.99/box/month (first set top box included, additional jacks cost time & material)

DVR Service $3.00/month

My TVs App

Watch TV Everywhere

Total # of boxes

blueSURGE Internet Service

_{*All speeds are "up to" the speed listed. Certain restrictions do apply. User experience is influenced by devices being used and performance capability of those devices as well as wireless router capability and environmental conditions.}

Agreements & Terms

General Terms and Conditions of Service

Agreement for blueSURGE Internet Service

Agreement for blueSURGE Television Service

Driver's License Upload

Upload a photo of your valid driver’s license for verification purposes.

Signature of the Applicant and Co-Applicant Applying for Service

Applicant

I certify by checking this box, the acceptance of service will have the effect of the person signing the application. Griswold Communications reserves the right to evaluate applicant credit for service consideration.

I agree to all Terms and Conditions of this Griswold Communications blueSURGE internet service application/agreement.

I agree to all Terms and Conditions of this Griswold Communications blueSURGE television service application/agreement.

Co-Applicant (if applicable)

I certify by checking this box, the co-applicant is also responsible for the account. Griswold Communications reserves the right to evaluate applicant/co-applicant credit for service consideration.