River Canyon Wireless – Sign Up

All fields must be completed before we will process the service application. First month is due at the time of install. Payments may not be accepted onsite. Alternatively, you may download a printable PDF application and mail or carry it in. Payment for install and the 1st month of service is required when install is completed. Install Technician may accept Cash, Check or Credit/Debit card. We reserve the right to use this information to carry out a credit check for service.

All fields marked with a * are required.

First Name:*

Last Name:*

Spouse Name:

Subscriber Date of Birth:*

Drivers License/ID #:*

ID State:* -- Choose -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington D.C.

Physical Street:*

Physical City:* Moab Blanding Monticello Castle Valley Bluff Bridgerjack Green River Price Helper Wellington Spring Glen Huntington Castle Dale Orangeville Ferron Clawson Elmo La Sal

Physical State:* Utah

Physical Zip Code:*

Mailing Address: Mailing Address same as Physical Address.

Mailing Street:

Mailing City:

Mailing State: -- Choose -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington D.C.

Mailing Zip Code:

Home Phone:*

Cell Phone:

Work Phone:

Email Address:

Paperless Billing: I would like to receive my billing statements by email.

The cost of a wireless Router is not included in the install fee or the monthly rate. Routers are customer owned and purchased. If you would like to use the Internet on multiple devices, or you would like to have wireless inside your home, you will need your own router. If you do not already have a router, our technician can sell you one when he is installing your connection. The router our technician sells is $49.99 + Tax.

An install fee of $54.99 plus the first months service rate must be paid at the time of the installation. Please be prepared to pay at the time of your install. Installers can accept cash, check, credit or debit card on site.

Internet Service Plans (Pick One):*

Bluff customers must pay a monthly B.O.B fee (Business Owner of Bluff). Residential customers pay $5 a month. The business fee is $10 a month. This is for construction and maintenance of the Equipment in Bluff

Both Subscriber and Landlord/Property Owner lines must be filled out in order to process this application. We must have both the Subscriber and the Property Owners names, even if they are the same person. By typing your name in the Digital Signature field you are legally digitally signing this application.

Online Account Access: I would like to sign up for Online Account Access (Subject to Website Terms & Conditions.)

Preferred Username:

Preferred Password:

Terms of Service:* I have read and agree to the Wireless Internet Service Agreement.

Subscriber Full Name (Digital Signature):*

Is this building a rental:* Yes, Building is a rental.

CAPTCHA Verification:*