Charter + All other Providers Order Form

Charter + All other Providers Order Form

You can reach us at 1-800-272-4309 with any questions
Please let us know which provider you have interest in
Customer Name*

First NameLast Name
Email Address *
example@example.com
Best Contact #*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact #
Please enter a valid phone number.Format: (000) 000-0000.
Service Address*

Street Address

Street Address Line 2

CityState

Zip Code
Important: Which provider are you with now & what SERVICES do you currently have?*
Provider name / Satellite / Cable / Internet
Did you just move into the home & are you looking for brand new service?*
Yes or No
Please select the Charter package you would like to order: (Choose one)*

Charter triple play - Select Bundle package - 125 Channels = $99.99 per mo.Charter triple play - Silver Bundle package - 175 Channels = $119.97 per mo.Charter triple play - Gold Bundle package - 225 Channels = $139.97 per mo.Charter - Cable TV ONLY - Select package - 125 Channels = 59.99 per mo.Charter - Cable TV ONLY - Silver package - 175 Channels = 79.99 per mo.Charter - Cable TV ONLY - Gold package - 225 Channels = 99.99 per mo.Charter Internet ONLY - 100mbps = $44.99 per mo.Charter Upgraded Ultra Internet (400mbps) = $69.99 per mo.
Would you like to add WIFI for $5 extra per month?*

Yes. I need WIFI added.NO, I do not want the WIFI added.
Would you like to add Premium Channels to your package?:*

HBO = $15 per monthShowtime = $15.00 per monthCinemax = $15.00 per monthStarz = $15.00 per monthNO, I do not want any additional Premium channels
How many Cable Boxes do you need? Each HD Box is $6.99 each) (If the customer wants DVR service to 1 Box, the cost is an additional $12.99 per month / If the customer wants DVR service to 2-6 boxes, the cost is $19.99 per month)*

0123456
Would you like to add Frontier High speed dedicated Internet 200/200 for $39.99 per mo. (WIFI Included) bundled with DISH Network*

Yes, I want High Speed Internet with Frontier.No, I do NOT want Frontier Internet service.
Would you like to add Frontier Home phone service for $35 per mo (Must be bundled with Internet)*

Yes, I want like to add Home phone service with Hughes for an additional $24.95 per monthNo, I do NOT want Hughes Home phone service
Select the best time for an agent to call you back with a free quote?*
Is there a specific time you would prefer us to call?
Should be Empty: