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Representative Information
Representative's Name
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Last
Representative's Email
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This will be used if we need to confirm the information on your order.
Phone Number
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Where can the representative be reached?
ATT Code
DTV Code
Do you intend to revisit the customer?
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Customer Information
Customer Name
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Shipping Address
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Street Address
Address Line 2
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ZIP Code
Customer's Email
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CBR Number
Cell or Home Phone?
Cell Phone
Home Phone
Best Time To Contact?
Morning (10:00-Noon)
Afternoon (Noon-5:00)
Evening (5:00-9:00)
Which Plans?
*
Internet
TV
Home Phone
Wireless
For Internet / TV / Home Phone
Internet Plans
None
INT 300 60.00
INT 500 70.00
INT 1000 80.00
INT 2000 110.00
Other
Other Internet Plan
TV Plans
None
ENTERTAINMENT 69.99
CHOICE 89.99
ULTIMATE 104.99
PREMIER 149.99
OPTIMO MAS 74.99 (MOST DO SPANISH OR DEPORTES ADD ON INSTEAD OF DOING OPTIMO MAS)
Other
(NOT INCLUDING RECIEVER PRICE OR AUTO PAY DISCOUNTS)
Other TV Plan
Home Phone Plan
None
Unlimited North America
Other
Other Home Plan
Home Phone Number
For Wireless
Number of Lines
Please enter a number from
0
to
10
.
Line 1 Wireless Plan
None
Starter
Extra
Premier
Line 1 Cellular Telephone Network (CTN)
Line 1 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 1 Other Device Choice
Line 2 Wireless Plan
None
Starter
Extra
Premier
Line 2 Cellular Telephone Network (CTN)
Line 2 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 2 Other Device Choice
Line 3 Wireless Plan
None
Starter
Extra
Premier
Line 3 Cellular Telephone Network (CTN)
Line 3 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 3 Other Device Choice
Line 4 Wireless Plan
None
Starter
Extra
Premier
Line 4 Cellular Telephone Network (CTN)
Line 4 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 4 Other Device Choice
Line 5 Wireless Plan
None
Starter
Extra
Premier
Line 5 Cellular Telephone Network (CTN)
Line 5 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 5 Other Device Choice
Line 6 Wireless Plan
None
Starter
Extra
Premier
Line 6 Cellular Telephone Network (CTN)
Line 6 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 6 Other Device Choice
Line 7 Wireless Plan
None
Starter
Extra
Premier
Line 7 Cellular Telephone Network (CTN)
Line 7 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 7 Other Device Choice
Line 8 Wireless Plan
None
Starter
Extra
Premier
Line 8 Cellular Telephone Network (CTN)
Line 8 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 8 Other Device Choice
Line 9 Wireless Plan
None
Starter
Extra
Premier
Line 9 Cellular Telephone Network (CTN)
Line 9 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 9 Other Device Choice
Line 10 Wireless Plan
None
Starter
Extra
Premier
Line 10 Cellular Telephone Network (CTN)
Line 10 Device Choice
None
IPHONE 14, PRO, PRO MAX, AND PLUS
IPHONE 13, PRO, AND MINI
IPHONE 12 AND MINI
SAMSUNG GALAXY A13 (5G)
GALAXY S22 (PLUS AND ULTRA)
GOOGLE PIXEL 6 AND 7 (PRO)
MOTOROLA G STYLUS 5G
SAMSUNG GALAXY FLIP AND FOLD 3&4
BYODS
Other
Line 10 Other Device Choice
Current Carrier
*
Account Number
Notes or Special Instructions
Notes or Special Instructions