Your Name

First Name

Last Name

Best Phone Number to Reach You

(###)

###

####

Cell or Work phone (you)

(###)

###

####

Cell or Work phone (spouse)

(###)

###

####

Your Service Address

Your Mailing Address (if different than service address)

Best Email Address to Reach You

Do you want a "@myfmtc.com" email address?

If so, please type your desired email address below.

Choose how you would like to receive your bill (pick 1 or both)

eBill

Paper via Mail

Your County

Adams

Montgomery

Page

Taylor

Internet

Includes unlimited use (no data caps), same speed for upload & download, ProtectIQ & FMTC Connect App. One time $50 installation for Internet. Please select which product you would like.

250Mb - $75.95/mo

500Mb - $105.95/mo

750Mb - $149.95/mo

1000Mb (1Gig) - $199.95/mo

Router

A router is required for connection to FMTC services. Please choose one.

u4 WiFi Router - $5.95/mo

u6 WiFi Router includes Experience IQ - $9.95/mo

Internet Add-Ons

GigaMesh WiFi Extender - $3.95/mo

DHCP IP Reservation - $5.00/mo

Phone

Includes Calling & Caller ID. Must have Internet to get phone service. One time $50 installation for Phone.

Phone service - $6.95/mo (unlimited nationwide & local area calling, no international calling)

Maintenance

Covers repair costs of wiring inside your home. Does not cover customer-installed wiring. Other restrictions may apply.

Whole Home Wire Maintenance - $3.50/mo

Authorized contacts for Privacy & CPNI

Keeping your information private is important to us. In keeping with the Customer Proprietary Network Information (CPNI) rules, we are asking that you provide the information below, so that we can confirm with whom we are speaking when you contact us by phone. Additionally, you may add other ‘authorized’ users to your account. They can be anyone that you wish, or those that need to have access, to make changes to your account with us.

Check if you DO NOT wish to add authorized contacts

No other authorized contacts wanted

What is your mother's maiden name

This will be your authorization password

Assistance Programs

Financial assistance is available for eligible Iowans to help them afford basic telephone and/or broadband service thru Lifeline.

I'm interested in learning more about Lifeline

Automatic Payments

For security reasons, we will contact you to set this service up.

Yes, I'm interested in Electronic, Automatic payments. Please contact me.

Customer Compliance & Service Agreement

By establishing an account with FMTC or using any software provided, developed, licensed, or owned by FMTC, I agree to be bound by this Agreement and to use the Services in compliance with this agreement and other FMTC policies posted and updated from time to time on FMTC’s website at www.myfmtc.com. I understand that all charges listed on this application (except installation) are monthly and do not include taxes and regulatory fees. Internet installation includes: router install, 1 jack if needed, tech assistance with connected devices. Installation of 2 services includes Internet and phone installation + additional jack if needed. Hardware remains property of FMTC. If a new fiber drop is needed, the cost of the first 500’ is covered by FMTC. Distance beyond 500’ will be quoted and paid by customer. I understand that I must keep services for at least 12 months and if I don’t, I will be charged a break fee equal to the cost of my monthly services times the number of months remaining to reach 12 months. I authorize FMTC to install all appropriate equipment for the services I have requested. I understand that all policies and procedures can be found on FMTC’s website or provided on request. All adults on the account are required to sign this application. (If you have multiple names to enter, please separate them with a comma and a space.)

Additional notes

Thank you for submitting your application for service to FMTC. We appreciate it and look forward to serving you with FMTC Fiber Internet.

We will contact you when it is time to schedule your appointment for installation.

Residential Application

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