REX TECH SETUP PAYMENTS FORM
Name
First Name
Last Name
Email
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
One-Time Setup Fee
$55.00
$
55.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 1 Service Pack
$25.00
$
25.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 3 Service Packs
$45.00
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monthly Payment - 5 Service Packs
$75.00
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Reconnection Late- Fee
$15.00
$
15.00
Quantity
1
2
3
4
5
6
7
8
9
10
Firestick Purchase
$35.00
$
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: