Better Rate Solutions – Customer Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which services would you like help lowering?
*
Internet
Cable/TV
Cell phone
Landline
Service provider name
*
Account number
Current Monthly Bill Amount
Account holder's name (if different from yours)
Provider account security PIN/passcode (if required)
Only your provider's account security PIN/passcode. No online passwords, Social Security numbers, or one-time verification codes.
Preferred contact method:
*
Email
Phone call
Text message
Best time to contact you (including your time zone)
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What would you like help lowering or changing about your bill?”
Upload Your Current Bill (Optional)
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