Residential Sales Consultant Form Order Date Install Date Requested Install Time Requested AM (8-11) Noon (11-2) PM (2-5) All Day Subscriber Name First Last Date of Birth Social Security Number Drivers License Number State Issued State Issued - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Expiration Date Home Phone Cell Phone Service Address Address Address 2 City/Town State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Mailing Address Same As Service Address Mailing Address Address Address 2 City/Town State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email Status message Cable Service Options Cable Services Basic Expanded Basic StreamTV Basic StreamTV Expanded Basic Cable Services Total Status message Channel Guide Free for One Month! Channel Guide Magazine Yes No Status message Cable TV Add-Ons Cable Services Digital Basic Digital Plus HD Ultra HBO Showtime Cinemax Starz/Encore MGM+ Other Cable Add-Ons Services Total Status message Cable TV Equipment HD DVR Quantity StreamTV Equipment Quantity Cable Equipment Total Status message Internet Options - NON GPON AREAS Internet Options FreeNet ACP ONLY - 105 105/20 MBPS Starter High Speed Internet 150/5 MBPS Essential High Speed Internet 250/10 MBPS Ultimate High Speed Internet 550/12 MBPS ACP ONLY - 650 650/15 MBPS *Choctaw Region Only Supreme High Speed Internet 1000/20 MBPS Status message Internet Options - GPON AREAS Fiber Internet Options ACP Only - 105/105 Fiber 250 Fiber 550 MaxxAdvantage 650 - *Choctaw Region Only Fiber 1000 Fiber 2000 Fiber 4000 Fiber 6000 Fiber 10000 Internet Service Total Status message Internet Equipment Options Internet Equipment Options Wired Modem Wireless Modem Customer Owned Internet Equipment Total Status message Digital Phone Service CPNI ? Phone Number Options Hosted Number Ported Number Number to Port Listings Published Unpublished Digital Phone Service Total Additional Phone Lines Additional Phone Line Total Status message Other Services Ancillary Service Options SmartNet SAP Service Assurance Plan Brainiacs Number of Beacons Ancillary Service Total Status message Installation Services Installation Options New Install Reconnect Install Change of Service Additional Outlets Installation Total Status message Package Summary Package Total Comments Comments Today's Date Sales ID Number Amount Pre-Paid to the Sales Rep Payment Type Cash Check Card Other COD Amount to Pay Installer Estimated Monthly Rate Signature Sign above Subscriber Full Name Full Name RSC Signature Sign above RSC Name Full Name RSC Email Leave this field blank
