REX TECH SETUP PAYMENTS FORM
Name
First Name
Last Name
Email
example@example.com
Cell Number
Please enter a valid phone number.
Today's Date
-
Month
-
Day
Year
Date
Name Of Person Who Referred You:
My Products
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next
( X )
One-Time Setup Fee
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 1 Service Pack
$
20.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 3 Service Packs
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 5 Service Packs
$
65.00
Quantity
1
2
3
4
5
6
7
8
9
10
Reconnection Late- Fee
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
Firestick Purchase
$
35.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: