Directv/AT&T Service Order Form
Visionary Associates, Inc.
Full Name
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Street Address
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Afghanistan
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Phone Number
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Area Code
Phone Number
Alternate Phone Number
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Area Code
Phone Number
E-mail
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Date Of Birth
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Month
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Day
Year
Date
Social Security #
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Drivers License #, Expiration Date, Issuing State
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Please Create a 4 Digit Pin #
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Please create a short security question and answer
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Please Select Your Package - Enroll in auto-pay and paperless billing and receive a $5 discount on your package each month!
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Select package 155+ channels no sports $ 64.99/mo.
Entertainment package 160+ channels some sports $69.99/mo.
Choice Package 185+ channels sports & 2019 NFL Sunday Ticket $74.99/mo.
Extra Package 235+ channels with NBA TV $84.99/mo.
Ultimate package 250+ channels with ALL sports $89.99/mo.
Premier Package 330+ channels All Included $139.99/mo.
Regional Sports fee On the Choice Package and up $5/mo.
How many TV's
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Are you interested in internet?
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Internet Packages
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Speeds Up To 100 mgbs. $40/mo.
150 to 300 mgbs. $40/mo.
500 to 1000 mgbs. $80/mo.
not interested
Stand-alone internet with speeds up to 300 mgbs where available $50/mo.
If AT&T Internet is unavailable are you interested in:
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Hughesnet
Local Internet Provider
Viasat
none
If Internet is not available, do you want to continue with your Directv Order? If no your order will not be processed.
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Preferred Installation Time
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8 AM - 12 PM
12 PM - 4 PM
Best Day for your installation
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Are you interested in Wireless Service?
Sales Agent
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Please double check all information provided is correct to avoid processing delays. After your order is submitted, please be ready for a call from our call center to confirm your order and receive your install date and time.To the best of your knowledge, you do not have a past due bill with AT&T wireless, U-verse or Directv. If you do, you will NOT qualify for service. With permission, you may complete this form with a friend or family members information.I understand with the submission of this order form I am agreeing to sign up for services. I understand my personal information will not be saved nor shared. All personal information will be used solely to process this order for service. All DIRECTV offers require 24-mo. TV agreement. $19.95 ACTIVATION, EARLY TERMINATION FEE OF $20/MO. FOR EACH MONTH REMAINING ON AGMT., EQUIPMENT NON-RETURN & ADD’L FEES APPLY. Price incl. TV Pkg., monthly service and equip. fees for 1 HD DVR & is after $5/mo. AutoPay & paperless bill discount for 12 mo. New approved residential customers only.
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I have read and agree to the Terms and Conditions
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