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TV Internet Packages $29.99 per service bundle

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No credit check Packages Available: (select the package you would like to order)*

triple play - Select Bundle package - 125 Channels = $99.99 per mo.triple play - Silver Bundle package - 175 Channels = $119.97 per mo.triple play - Gold Bundle package - 225 Channels = $139.97 per mo.Cable TV ONLY - Select package - 125 Channels = 59.99 per mo.Cable TV ONLY - Silver package - 175 Channels = 79.99 per moCable TV ONLY - Gold package - 225 Channels = 99.99 per mo.Internet ONLY - 100mbps = $44.99 per mo.Upgraded Ultra Internet (400mbps) = $69.99 per mo.

Important: Which provider are you with now & what SERVICES do you currently have?*

Did you just move into the home & are you looking for brand new service? or looking to switch or disconnected Is this an Apt or house?*

Comments or additional instructions

Customer Name:*

First NameLast Name

Your E-mail*

Best Contact# - Home/Cell#:*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1st preference Appt DAY? (Will call to confirm) Installation *

Installation day

1st preference Appt time? (Will call to confirm)*

Installation day

2nd preference Appt DAY? In case the original Appt is not available?*

Installation day

2nd preference Appt time? *

Installation day

Date of Birth:*

Date

Billing address to the CC if different then Service Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

For identification purposes, please select a 4 digit pin# as this will be used if you should contact about your order in the future:*

Identification question = What is your favorite restaurant?*

In the unlikely event that your service gets declined with Hughes net, would you like to put a spouse or family member on file to get them approved as a backup for service? I would just need their FULL Name, DOB & Social? Otherwise type "NA"**

Should you not get approved for Hughes net Do we have your verbal permission to try & connect your service with other providers that may be available in your area?*

Notes / Comments or additional instructions:

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