Connect 66 Residential Internet Service Request Grants/Milan

875-E US Highway 491/PO Box 4011, Yatahey, NM 87375
Tel: (833) 463-0067        Fax: (505) 905-6001

RESIDENTIAL INTERNET SERVICE ORDER


NAME
FIRST AND LAST
This question is required
FIRST AND LAST
DATE OF BIRTH
/
/
Please enter a valid date
Social Security Number
XXX-XX-XXXX
This question is required
XXX-XX-XXXX
TELEPHONE NUMBER
This question is required
E-mail Address
Please enter a valid email
MAILING ADDRESS
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required
PHYSICAL ADDRESS
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required
EMPLOYER NAME
This question is required
JOINT APPLICANT (If Applicable)
Please provide the first and last name of joint applicant.
Please provide the first and last name of joint applicant.
DATE OF BIRTH
Please provide the birthdate of joint applicant.
/
/
Please provide the birthdate of joint applicant.
Social Security Number
XXX-XX-XXXX
XXX-XX-XXXX
TELEPHONE NUMBER
Additional Contact Reference
Please list the name, relationship and phone number of a contact reference.
This question is required
Please list the name, relationship and phone number of a contact reference.
Additional Contact Reference
Please list the name, relationship and phone number of a contact reference.
This question is required
Please list the name, relationship and phone number of a contact reference.
Additional Contact Reference
Please list the name, relationship and phone number of a contact reference.
This question is required
Please list the name, relationship and phone number of a contact reference.
Authorized Contacts
Please list the names and phone numbers of any individual(s) authorized to make changes on your account, or to call in and discuss your telephone bill, account services or balance due.
This question is required
Please list the names and phone numbers of any individual(s) authorized to make changes on your account, or to call in and discuss your telephone bill, account services or balance due.
ACCOUNT PASSWORD
Please provide an account password.
This question is required
Please provide an account password.
SECURITY QUESTION 1
What elementary school did you attend?
This question is required
What elementary school did you attend?
SECURITY QUESTION 2
What is your favorite number?
This question is required
What is your favorite number?
How did you hear about us?
Enter your E-mail address to sign up for paperless billing?
Higher speeds may be available in your area. Installation charges may apply. Not all speeds are available in all locations. High-speed internet subject to availability of facilities and capacity. Terms and Conditions apply.


RESIDENTIAL INTERNET PLANS
Residential Internet Plans
Prices shown are monthly rates. Select from the following 1-year or 2-year plans. Installation fees are waived on 2-year plans.
25 M 1-Yr Contract
$44.95 
50 M 1-Yr Contract
$54.95 
75 M 1-Yr Contract
$64.95 
100 M 1-Yr Contract
$74.95 
25 M 2-YR Contract
$34.95 
50 M 2-YR Contract
$39.95 
75 M 2-YR Contract
$44.95 
100 M 2-YR Contract
$49.95 
Prices shown are monthly rates. Select from the following 1-year or 2-year plans. Installation fees are waived on 2-year plans.
One Time Installation Fee
$



Monthly Modem Fee
$5.00

*Prices shown do not include taxes, fees and other charges  required by law.

By signing, I acknowledge I have read, understand, and agree to pay all one-time and monthly recurring fees applicable to the Service Plan(s) which I selected above, and I have read, understand and agree to all Terms and Conditions and not participate in Robocalling.

Sign here
This question is required
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SUBMIT

Sacred Wind is an equal opportunity provider and employer.

In accordance with Federal Civil Rights law and U.S. Department of Agriculture (USDA) Civil Rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior credible activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.