1. Name_ ____________________________________________________
Connecting you, your family, Address____________________________________________________
City _________________________State_____Zip Code_____________
your friends... your LIFE! Email____________________________Phone #___________________
 Rent  Own
1 Local/Long Distance Service 5 Mobile Application
Current Provider___________________________________________________________________ Do you make long distance or international calls on your mobile phone? Yes
 No

Primary Phone Number _____________________________________________________________ Are you interested in saving money on your mobile phone bill? Yes
 No

My monthly bill is approximately $___________________________________________________
• Bundled with:  Internet  TV  Both 6 TV Service
• Total Bill $_____________
Current Provider___________________________________________________________________
International Calls:  Yes  No
Long Distance:  Yes  No My monthly bill is approximately $___________________________________________________
I am interested in Unlimited Calling:  Yes  No • Bundled with:  Internet  Phone  Both
Number of receivers______ Months left on contract ______
2 High Speed Internet Service I currently have  HDTV  DVR
Current Provider___________________________________________________________________ 7 Home Security & Automation Service
My monthly bill is approximately $___________________________________________________
Current Provider___________________________________________________________________
• Type of Service:  Cable  Dial-Up  
DSL Wireless Aircard (Provider_______)
• Bundled with:  TV  Phone  Both My monthly bill is approximately $___________________________________________________
I am currently a: 
Homeowner Renter

3 Digital Phone Service  do not have home security service today, but I am interested more information.
I
 am interested in Home Automation service.
I
 you call anyone who you wish you could see more often?
Do
 am interested in Digital Phone Service (Unlimited Calling)
I 8 Computer Support
4 Wireless Service Current Provider___________________________________________________________________
Do you perform a regular backup of all your files? Yes
  No
Current Provider___________________________________________________________________ Have you ever had a computer virus? Yes
  No
 I love my current provider  I am open to using a different provider Amount spent on average computer repair incident $________
My monthly bill is approximately $_______ Minutes on plan______ Please select the type of computer support services you’ve used in the past
Months left on current contract ______ Number of phones on plan ______  Friend or Family Member  Remote Service
Do you currently have a texting plan?  Yes  No  National Provider  Self-help
Data Plan included?  Yes  No
I last upgraded my phone(s) approximately: ____ Months ____ Years 9 Energy
 like my handset
I  am interested in service without a contract
I
Current Provider___________________________________________________________________
 am interested in updating my handset
I or credit check
Type of Service  Natural Gas  Electricity 
Both
 am interested in a wireless card for my
I
laptop My monthly bill is approximately $____________
I am interested in the following: (check all that apply)
 Residential Electricity  Residential Natural Gas
 Business Electricity  Business Natural Gas
PERSON WHO INVITED ME: Total Monthly Bill Amount $__________________
COMMENTS: Total Yearly Bill Amount $__________________
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