New Customer Application

Save & Return

Use an account to return to saved work.

Do you already have an account with Varcomm? *

Yes

No

Thank you valued Varcomm customer! Please go to your account on Webself Care to add new services to your existing account.

www.varcomm.net. Hit "Pay my Bill" to get logged into your account.

Which exchange do you live in? *

First Name of Primary Account Holder *

Last Name of Primary Account Holder *

Would you like an additional name listed on the account? This person would have all the same rights as the primary owner of the account. This person would need to know the password set on the account in order to receive information pertaining to the account. *

Yes

No

First Name of Secondary Account Holder *

Last Name of Secondary Account Holder *

Service Address *

City *

State *

Zip Code *

Cell Phone Number *

Is your mailing address the same as your service address? *

Yes

No

Mailing Address *

City *

State *

Zip Code *

I agree that the mobile number provided, may be used for SMS/Text Messages to me regarding information about my application for service, installation, general services, appointment times, billing, account balance, due date and repair of service for Varcomm service. If my wireless or mobile provider charges me for receipt of such messages, I acknowledge and agree that I am responsible for paying such charges. I may revoke this authorization insofar as it relates to SMS/Text messages at any time by calling or writing my local Varcomm office. I agree to identify my service provider and provide a valid mobile phone number for this service.

Do you agree? Texting and other charges may apply. *

Yes

No

Please select your cell phone carrier. We need this in order to send text messages to your phone. If at any time you would like to opt out of receiving text messages you will need to contact our office at 888-539-5234. *

Email Address *

I agree that the email address, including that of a wireless or mobile device, provided may be used for to notify me regarding information about my application for service, installation, general services, appointment times, billing, account balance, due date and repair of service for Varcomm service. If my wireless or mobile provider charges for receipt of such messages, I acknowledge and agree that I am responsible for paying such charges. I may revoke this authorization at any time by calling or writing my local Varcomm office.

Do you agree? *

Yes

No

Social Security Number. *

Driver's License Number *

Date of Birth *

MARKETING CONSENT TO PHONE AND EMAIL CONTACT

CONTACT BY PHONE: I consent to Varcomm calling the phone number(s) I provided for any purpose, including the marketing of its current and future services. I agree that these phone calls may be made using any method, including an automatic dialing system, or an artificial or recorded voice. Upon My request, the phone numbers I have provided willl be removed from Varcomm’s phone marketing list. I may revoke this authorization insofar as it relates to marketing messages at any time by calling or writing my local Varcomm office and asking to be placed on Varcomm’s Do Not Market List. I acknowledge that being included in any state or federal “do not call” registry will not be sufficient to remove me from Varcomm’s phone marketing list.

Do you consent? *

Yes

No

CONTACT BY EMAIL: I consent to Varcomm emailing me, at any email address, including that of a wireless or mobile device, that I provide to Varcomm, for any purpose, including the marketing of Varcomm’s current and future Services. If my wireless or mobile provider charges me for receipt of such messages, I acknowledge and agree that I am responsible for paying such charges. I may revoke this authorization insofar as it relates to marketing messages at any time by calling or writing my local Varcomm office.

Do you consent? *

Yes

No

Account Password Protection

Your privacy Matters!

Varcomm is dedicated to protecting your privacy. In accordance with Federal Communications Commission's rules governing your Customer Proprietary Network Information (CPNI), we require your account to be password protected. You and anyone you add as an authorized person on your account will be required to provide us the password that you set up in order to receive any information concerning your account.

What password would you like to set for your account? This can be anything, alphanumeric, names, colors, numbers, anything that you will remember when requesting information about your account. *

Forgotton Password Questions: Please choose at least one (1), but up to four (4) of the password recovery questions below. We will ask you one of these questions if you forget the password that you assigned to your account. *

	Answer (Input N/A if you don't want to answer)
What is your favorite color?	Answer (Input N/A if you don't want to answer)
What is your favorite sports team?	Answer (Input N/A if you don't want to answer)
What is your pet's name?	Answer (Input N/A if you don't want to answer)
What is your favorite hobby?	Answer (Input N/A if you don't want to answer)

What services would you like to sign up for? *

Phone Only

Phone & Broadband

Broadband Only

What services would you like to sign up for? *

Phone & Broadband

Broadband Only