Canby Telcom

Care

Residential Service

Service Request Form - Residential

View the Consent for Service

Personal Information


First Name
Last Name
Middle Initial
19
Date of birth
Social Security Number:
Oregon Drivers License

Employed by
How long?
Contact phone number

Email address (optional)

Spousal Information


First Name
Last Name
Middle Initial
19
Date of birth
Social Security Number:
Oregon Drivers License

Employed by
How long?
Work phone number

References


First name
Last name
Phone number

First name
Last name
Phone number

Service Address


Street address
City
State
Zip code
Type of Residence:
Own
Rent
Landlord

Billing Address

Same as Service Address


Street address
City
State
Zip code

What Type of Service(s)

Phone:
None
Flat Rate
Measured Service
 Add Unlimited Long Distance

Internet:
None
Dial-Up
High-Speed (DSL)

 We will tell you what speeds are available at your service address when we call.

TV:
None
Basic TV
Essentials TV Latin Essentials

 Premium Channels

Service Packages:
None
Gold: Phone and High-speed Internet
Triple Play: Phone, High-speed Internet, and TV

Comments or Other Products

Before Submitting information please read the Consent for Service

  

We will call you to confirm service and pricing.