DirecTV / Hughes Order Form:
(This Order form is intended for Internal Office use only)
Customer Name
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First Name
Last Name
E-mail
*
Best Contact# - Home/ Cell#
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-
Area Code
Phone Number
Service Address
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Street Address
Is this an Apartment or house? (MUST get Apt# or Lot#)
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
Billing address to the CC if different then Service Address:
Street Address
Is this an Apartment or house? (MUST get Apt# or Lot#)
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 & what SERVICES do you have NOW?
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List PROVIDER & SERVICES you have NOW?
Did you just move into the home & you're looking for Brand New Service?
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YES
NO
Please select the DirecTV package you would like to order:
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Select package = 155+ Channels - $59.99 per month
Entertainment package = 160+ Channels includes Lifetime Movie Network - $64.99 per month
Choice package = 185 Channels includes Sports pack - Sunday NFL ticket, Red zone channel & (LMN) Lifetime Movie Network - $69.99 per month
Xtra package = 235+ Channels (Most Popular package - All Included) = $79.99 per month
Ultimate package = 250+ Channels (The Movie-Lovers package) - All Included) = $84.99 per month
Premier package = 330+ Channels (Top of the line - All Included) TV Watchers Dream = $134.99 per month
HBO, Cinemax, Showtime Starz & EPIX channels are FREE for 3 months. After 3 months, you will be billed $53.99 a month. Would you like me to add these Premium channels to your package FREE of charge for 3 months? You would just need to cancel the subscription before the promotional period ends so you will not be billed. OK. (Make sure Customer understands this)
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YES, please add the Premium channels FREE for 3 months.
NO, I do not want the Premium channels FREE for 3 months.
How many Boxes? You get the 1st HD DVR box Free. (Each additional HD DVR Box is $7.00 per box, per month)
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1
2
3
4
5
6
Would you like to bundle High Speed Internet from AT&T (50mbps) with your DirecTV service for $30.00 a month extra? (WIFI Included)
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Yes, I want High Speed Internet with AT&T
No, I do not want Internet with AT&T
If AT&T is NOT available in your area, would you like to bundle 10 GB of High Speed Internet from HUGHESNET with your DirecTV service for $39.99 + $9.98 to lease the equipment = $49.97 a month extra? (IMPORTANT - MUST tell the customer: The 1st month + the cost to lease the equipment will be charged today to schedule the Hughes Installation)
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Yes, I want 10 GB Internet with HUGHESNET (Ideal for single users & Couples - (WIFI is INCLUDED) $49.99 per month - (Not Bundled with DirecTV)
Yes, I want 20 GB Internet with HUGHESNET (Best for Families with kids streaming Netflix & HULU - (WIFI is INCLUDED) $59.99 per month with DirecTV Bundle
Yes, I want 30 GB Internet with HUGHESNET (Ideal for the entire household with multiple devices - (WIFI is INCLUDED) $69.99 per month with DirecTV Bundle
Yes, I want 50 GB Internet with HUGHESNET (All the DATA you can handle - Unlimited - (WIFI is INCLUDED) $89.99 per month with DirecTV Bundle
NO, I DO NOT WANT HUGHESNET
HUGHES Home Phone service ADD-ON:
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Yes, I would also like to add the Home phone service for an additional $24.95 per mo. (Home Phone service MUST be bundled with Internet) (We do not sell the Home phone as a stand alone service) (1st Month charged today)
No, I do not want Home phone service with HUGHESNET.
AT&T Home Phone service ADD-ON:
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Yes, I would also like to add the Home phone service for an additional $24.95 per mo. (Home Phone service MUST be bundled with Internet) (We do not sell the Home phone as a stand alone service) (1st Month billed 30 days after Installation)
No, I do not want Home phone service with AT&T.
Tentative Installation Day (1st Preference Appt day - will call to confirm)
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Tentative Installation Time (1st Preference Appt time - will call to confirm):
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Morning from 8am - 12pm
Afternoons from 12pm - 4pm
One time Activation fee of $19.95 which is charged today. Installation is FREE - ($199 value):
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I understand & agree. Please let customer know.
Date of Birth:
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Month
-
Day
Year
Example: 12-02-1980
Do I have your verbal authorization to charge your credit card $19.95 for the one-time activation fee to schedule the DirecTV service:
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Yes. You have my verbal authorization to charge my credit card for $19.95
Important: We also want to let you know that you can begin streaming DirecTV Data FREE from your Smart TV, I-phone, Android, I-pad or tablet prior to your Installation absolutely FREE of charge. All you have to do is download the DirecTV App & enter your Account#.
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Yes. I understand I can stream DirecTV FREE of charge before my Installation.
ASK CUSTOMER: For security purposes, please select a 4 digit pin# as this will be used if you should contact DirecTV about your order in the future:
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4 Digit pin#
ASK CUSTOMER: Security question= What is your favorite restaurant?
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Security answer
Should you not get approved for DirecTV, Do we have your verbal permission to try & connect your service with other providers that may be available in your area?
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TYPE: YES OR NO
Agents name / Call Center Name:
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First & Last Name / Call Center name:
Agents best contact#:
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Agents Contact#:
Agents Email address:
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Agents Email Address:
Notes / Comments or additional instructions (Do Not Include customers sensitive info in the Notes below)
Submit Order
Should be Empty: