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 Name
Last 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
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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 month
Showtime = $15.00 per month
Cinemax = $15.00 per month
Starz = $15.00 per month
NO, 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)
*
0
1
2
3
4
5
6
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 month
No, I do NOT want Hughes Home phone service
Select the best time for an agent to call you back with a free quote?
*
Please Select
9:00 AM - 12:00 PM
12:00 PM - 5:00 PM
5:00 PM - 9:00 PM
Is there a specific time you would prefer us to call?
Submit
Should be Empty: