Mid Century Fiber Sign-up and Interest First Name * Last Name * Address * Your Fiberhood City * State * Zip * Preferred contact method * Email Phone Email ( All correspondence including your service agreement, installation scheduler, and billing information will be sent to this email address. ) * Home Phone * Cell Phone Do you rent the property? * Yes No Landlord Name * Landlord Contact Number * Is your billing address different than your service address? * Yes No Billing Street Address * Billing City * Billing State * Billing Zip * Are You a Current Mid Century customer? * Yes No Ready to Sign up, or just getting info at this time? * I'm ready to Sign Up. I'm interested, but need more info (please continue to fill out form and we will contact you back) Please select your Service Package * PackageSpeedPre-Registration InstallationPre-Registration PricingStandard InstallationStandard Pricing Ultimate Gigabit 1,000 MbpsFree!$74.95/mo$100.00$99.95/mo Elite 250 MbpsFree!$59.95/mo$100.00$69.95/mo Basic 50 MbpsFree!$49.95/mo$100.00$59.95/mo Please select your Service Package * PackageSpeedPre-Registration PricingPre-registration Installation Special*Standard Pricing Ultimate Gigabit 1,000 Mbps$74.95/mo$199.00$199.95/mo Elite 250 Mbps$59.95/mo$199.00$69.95/mo Standard 50 Mbps$49.95/mo$199.00$59.95/mo *$199 pre-registration/standard installation includes drop to home up to 200’ plus equipment and install in the home. Additional footage will be charged accordingly with 50% due prior to drop being placed. Remaining 50% will be billed. Managed Wi-Fi * SmartNet Wi-Fi $6.95 SmartNet Wi-Fi Advantage $10.95 Local Phone Service * Local Phone $23.00/mo per line No Thank You Includes Unlimited Local Calling, Unlimited Long Distance to US 50, Canada, Puerto Rico, and US Virgin Islands (certain taxes apply), Voicemail & Calling Features, Plus keep your same phone number. Publish or Non-published Phone Number Publish My Phone Number Do Not Publish My Phone Number $1.00/month Number of Phone Lines * 1 2 Would you like to keep your current phone number? * Yes No Current Phone Number * Current Phone Number Line 2 Who Is Your Current Phone Provider * AT&T Comcast Frontier AT&T Mobility US Cellular Mediacom CenturyLink Would you like voicemail included with your phone line? Please note that voicemail is not needed if you currently use an answering machine. * Yes, I would like voicemail included No thanks, I will keep my answering machine UPS Battery - Note: Phone service will NOT work in case of power outage without a UPS battery backup installed. This is not mandatory, but without it, access to E911 will not work when power is out. * Yes - I want a UPS for only $2.50/mo (Mid Century will monitor battery and replace when needed) No - I elect NOT to use a UPS and I understand the risk Bill Pay Options * Email Bill and Auto Pay via (Checking Acct) Email Bill and Auto Pay via (Credit or Debit Card) Email Bill and Mail in Payment Paperbill (addl $2/mo charge) and Mail in Payment Undecided How did you hear about Mid Century Fiber? * Website Direct Mail letter/postcard Yard Sign Radio Ad TV Ad Newspaper Ad A Friend Door to Door Salesperson Event Newspaper Article TV News Story Twitter Facebook Radio Talk Show Ad on side of Vehicle Email Billboard LinkedIn Please let us know which Sales Rep you talked to, Thanks. Nick Hoffman Rosie Kling Brenda Sprague Mike Ridder Ryan Buehler Hayden Douglas Jeremy Heaton Jess Van Beck Please write in anything that our construction crews need to be aware of in your yard. (Dog Fence, Sprinkler System, etc) Questions or Comments Pay Pre-Registration sign-up fee * Via Paypal with Credit or Debit Card By Contacting Mid Century at 309 - 778 - 8611 Pay By Check Terms and Conditions * I agree to Terms and Conditions Terms and Conditons * I agree to Terms and Conditions
309 - 778 - 3278
