Application for Membership You, the Applicant, whether one or more (joint members), or the legal representative of a Virginia business entity, hereby applies for membership in the Powhatan Internet Cooperative, a Cooperative Corporation, hereinafter called the Cooperative and in consideration of this application hereby agree as follows: To pay the Cooperative the established membership fee of $10. As the Cooperative makes Internet services available, the applicant agrees to purchase from the Cooperative service to be used on the premises described below and to pay therefore monthly rates which from time to time be fixed by the Board of Directors. To be bound by and to comply with all applicable laws and regulations of the Cooperative's Articles of Incorporation, Bylaws, consumer classifications, rates, charges, and service rules and regulations and the terms of the Cooperative, both as the same now exist or may hereafter be adopted, repealed, amended or supplemented. To grant the Cooperative right-of-way easements for extending and furnishing service to the applicant and/or for any other need of the Cooperative in constructing, operating, maintaining, and upgrading of its Broadband systems; and also the right to cut or trim trees necessary to keep them clear of all parts of such system including danger trees outside the specific right-of-way width. To cause such premises to be wired in accordance with the highest of whichever standards may be involved - applicable state or local government ordinances or the requirements of the Cooperative. If the owner or occupant of the premises described below shall cease to accept and pay for service to such premises or any part thereof, the lines affected thereby may be retired; whereupon, the labor costs incident to any reinstallations of such lines may be charged in full to the party desiring such reinstallation. All computer equipment within the premises - dwelling, out-buildings or located anywhere on the property of the undersigned are in a safe condition for the purpose of receiving Broadband service. The undersigned holds Powhatan Internet Cooperative harmless for any damage of any nature that may result from the installation of and the providing of service to my premises, which installation is done at my request and may be done without my presence at the time of such installation. I have been advised that equipment that is left connected or in faulty condition, the providing of service to such equipment in such condition, particularly if unattended, may result in damage to my property. The acceptance of this application by the Cooperative shall constitute a contract between the Cooperative and the undersigned upon the terms set forth.Type of Account*Select one...IndividualJointEntityYour Name* First Last Name of Joint Member* First Last Name of Entity*Type of Entity*Select One...Sole ProprietorshipLimited Liability Company (LLC)CorporationNon-profit (LLC or Corp)Federal EIN*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Website* Membership Fee* Price: $10.00 Total $0.00 Payment Option*Select One...Credit / Debit CardSend me a Paypal InvoiceCheckCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name I agree to the following:* I have read the Bylaws and understand my responsibilities as a member. I understand by joining the Co-op that I have not committed myself financially, nor am I personally liable for any financial decisions made by the Co-op. I understand that I will be subscribed to the monthly member newsletter, but that I may unsubscribe at any time. CAPTCHAEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
