Service Application Service Application Service Application Form Generic membership and service application form. Please note that a WCTA Account Representative will contact the phone number you've provided below to further complete our service application process. At that time, additional information like a social security number, credit card number, and other household information may be necessary. The call will be made during our business hours of 8:00am - 4:30pm, Monday - Friday. Name First Last Service Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Please check if the Billing Address is the same as the Service Address above Billing Address is the same Contact Phone Number*Local PhoneAre you interested in Local Phone Service? (e.g., a landline phone)* Yes No If yes, would you like to keep your same home phone number?YesNoBroadband InternetBy letting us know what types of activities you use your internet for, it allows us to better recommend the right bundle or service for you.How do you use your internet? Select All Streaming Services (Netflix, Hulu, etc.) Gaming Checking Emails/Webpages Home Management (Nest Thermostats, Alexa/Google Home, etc.) Other Preferred Email Address Digital TelevisionHow many TVs would you like to connect in your home?Please enter a number from 1 to 40.Are you interested in adding HD Channels?YesNoAre you interested in adding Cloud DVR service?YesNoAre you interested in any of our Premium Movie Channels? (HBO, Cinemax, Showtime, Starz)YesNoBundle SelectionAlready have a bundle in mind? Pick one of the following bundles.* Prices may vary depending on your location; an Account Representative will clarify pricing during our initial setup call.Bundle Options15Mbps Internet Only - $39.90100Mbps Internet Only - $109.00Premium 15 (Local Phone & 15Mbps Internet) - $61.20Premium 100 (Local Phone & 100Mbps Internet) - $64.95Premium DET (Local Phone, 100Mbps Internet, up to 2 views of Digital TV) - $140.50Premium DET - 4 Views (Local Phone, 100Mbps Internet, up to 4 Views of Digital TV) - $147.95 *More bundling options may be available depending on your location. Please call our business office at 1-800-592-6105 for more information.CommentsThis field is for validation purposes and should be left unchanged.