Webform This is a Presale Order This is a Fiber Conversion Order Date Install Date Requested Install Time Requested AM (8-11) Noon (11-2) PM (2-5) All Day (8-5) Install Date Requested 2 Install Time Requested 2 AM (8-11) Noon (11-2) PM (2-5) All Day (8-5) Install Date Requested 3 Install Time Requested 3 AM (8-11) Noon (11-2) PM (2-5) All Day (8-5) Subscriber Name First Last Suffix State Issued State/Province - 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 Expiration Date Home Phone Cell Phone Text Opt In? Yes No Service Address Address Address 2 City/Town State/Province - 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 Mailing address is the same as the service address. Mailing Address Address Address 2 City/Town State/Province - 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 Is this customer eligible for MaxxFiber services? - Select -YesNo RSC Only Offers SP: TiVo+ & Starter Internet$39.99 StreamTV Basic, TiVo+ & Essential Internet$89.99 StreamTV Expanded Basic, TiVo+ & Essential Internet$149.99 Streaming Services StreamTV Basic StreamTV Expanded Basic TiVo+ How many StreamTV boxes are needed? Channel Guide Free for One Month! Channel Add-Ons Digital Basic Digital Plus HBOIncludes access to Max! Paramount+ with Showtime Cinemax Starz/Encore MGM+ High-Speed Internet Options Rocket 600 Mbps$9.99/mo for 36mo - 600 Mbps Download / 20 Mbps Upload *Requires $50 one-time activation fee. Rocket 1 Gig$19.99/mo for 36mo - 1,000 Mbps Download / 20 Mbps Upload *Requires $50 one-time activation fee. Supreme Internet$39.99/mo for 36mo - 1,000 Mbps Download / 20 Mbps Upload *Requires $50 one-time activation fee. Starter Internet150 Mbps Download/5 Mbps Upload $19.99 for months1-3; $39.99 for months 4-6; $46.99 Essential Internet400 Mbps Download/10 Mbps Upload $59.99 Ultimate Internet600 Mbps Download/12Mbps Upload $79.99 Additional Services SmartNet Service Assurance Plan BrainiacsOnly $5 if added with SAP BARK Jr. Free Parental Controls App when signing up for MaxxFiber! BARK Premium WTFast Single WTFast Family Channel Guide Digital Home Phone Service - None -YesNo CPNI ? Phone Number Options Hosted Number Ported Number Number to Port Do you want your phone number listed? Yes No Additional Phone Lines Needed Number of Beacons Needed RSC Only Offers SP: TiVo+ & Fiber 200$39.99 StreamTV Basic, TiVo+ & Fiber 400$89.99 StreamTV Expanded Basic, TiVo+ & Fiber 400$149.99 Streaming Services StreamTV Basic StreamTV Expanded Basic TiVo+ How many StreamTV boxes are needed? Channel Guide Free for One Month! Channel Add-Ons Digital Basic Digital Plus HBOIncludes access to Max! Paramount+ with Showtime Cinemax Starz/Encore MGM+ None of the above MaxxFiber Options Rocket 600 Mbps$9.99/mo for 36mo - 600 Mbps Download / 20 Mbps Upload *Requires $50 one-time activation fee. Rocket 1 Gig$19.99/mo for 36mo - 1,000 Mbps Download / 20 Mbps Upload *Requires $50 one-time activation fee. Fiber 1 Gig$39.99/mo for 36mo - 1,000 Mbps Download / 1,000 Mbps Upload *Requires $50 one-time activation fee. Fiber 200200 Mbps Download/200 Mbps Upload $19.99 for 1-3 months; $39.99 for 4-6 months; $46.99 Fiber 400400 Mbps Download/400 Mbps Upload $59.99 Fiber 600600 Mbps Download/600 Mbps Upload $79.99 Additional Services SmartNet Service Assurance Plan BrainiacsOnly $5 if added with SAP BARK Jr. Free Parental Controls App when signing up for MaxxFiber! BARK Premium WTFast Single WTFast Family Channel Guide Digital Home Phone Service - None -YesNo CPNI ? Phone Number Options Hosted Number Ported Number Number to Port Do you want your phone number listed? Yes No Additional Phone Lines Needed Number of Beacons Needed Installation Type New Install Reconnect Install Change of Service Number of Additional Outlets Needed WordPress ID (Payment Confirmation) AutoPay Opt-In? Paperless Statement Opt-In? Estimated Monthly Rate Installation Total? Total Due Today Amount Pre-Paid to the Sales Rep Payment Type Cash Check Card Other Comments Customer Signature Customer agrees everything on the order is accurate. Subscriber's Full Name First Last Residential Sales Representative Sign above Residential Sales Representative First Last Residential Sales Consultant email Sales number/Tech ID/ Name Lease One file only.100 MB limit.Allowed types: gif, jpg, jpeg, png. License One file only.100 MB limit.Allowed types: gif, jpg, jpeg, png. Leave this field blank
