CBN STARTER KIT WITH ACCOUNTS APPLICATION
Hampton Roads
Your Name
*
First Name
Last Name
Company Name
(If already established)
E-mail
*
This will be our main line of communication
Phone Number
*
-
Area Code
Phone Number
Shipping Address (for your equipment and supplies)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Choose the cities you would prefer to provide service in most
1st Choice
2nd Choice
3rd Choice
4th Choice
5th Choice
City
Chesapeake
Hampton
Newport News
Norfolk
Portsmouth
Suffolk
Virginia Beach
Chesapeake
Hampton
Newport News
Norfolk
Portsmouth
Suffolk
Virginia Beach
Chesapeake
Hampton
Newport News
Norfolk
Portsmouth
Suffolk
Virginia Beach
Chesapeake
Hampton
Newport News
Norfolk
Portsmouth
Suffolk
Virginia Beach
Chesapeake
Hampton
Newport News
Norfolk
Portsmouth
Suffolk
Virginia Beach
CHOOSE PACKAGE
*
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( X )
PACKAGE A - $2,000 Per Month In Contracts
$
10,000.00
PACKAGE B - $4,000 Per Month In Contracts
$
20,000.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Signature
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