Sales

Customer Name*

First Last

Customer Phone Number*

(###) ###-####

Alternate Phone Number

(###) ###-####

Address*

Street Address Address Line 2 City State ZIP Code

Customer Email*

example@example.com

Customer Credit Card/Debt Card Number*

Customer Credit Card/Debt Card Expiration Date*

XX-XX

Customer Credit Card/Debt Card CVC*

Attach Additional Documentation (if needed)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, gif, tiff, Max. file size: 15 MB.

Service*

DIRECTV
AT&T Mobility
Viasat
Frontier
Windstream
CenturyLink
AT&T Broadband
ADT

Social Security Number*

Date of Birth*

Date of Birth

DIRECTV Package*

Entertainment
Choice
Ultimate
Premier

How to Watch?*

via Satellite
via Internet

Equipment

Number of TV's*

Driver License/ID Number*

Driver License/ID State Issued*

Driver License/ID Exp. Date*

Data Package*

NON UNLIMITED PACKAGE

Upgrade Frequency*

Number of Lines*

1st Device*

Make - Model - GB Size - Color

1st Device Porting Number?*

Yes
No

1st Device Porting Phone Number*

1st Device BOYD (Bring Your Own Device)*

Yes
No

1st Device IMEI Number*

2nd Device*

Make - Model - GB Size - Color

2nd Device Porting Number?*

Yes
No

2nd Device Porting Phone Number*

2nd Device BOYD (Bring Your Own Device)*

Yes
No

2nd Device IMEI Number*

3rd Device*

Make - Model - GB Size - Color

3rd Device Porting Number?*

Yes
No

3rd Device Porting Phone Number*

3rd Device BOYD (Bring Your Own Device)*

Yes
No

3rd Device IMEI Number*

4th Device*

Make - Model - GB Size - Color

4th Device Porting Number?*

Yes
No

4th Device Porting Phone Number*

4th Device BOYD (Bring Your Own Device)*

Yes
No

4th Device IMEI Number*

5th Device*

Make - Model - GB Size - Color

5th Device Porting Number?*

Yes
No

5th Device Porting Phone Number*

5th Device BOYD (Bring Your Own Device)*

Yes
No

5th Device IMEI Number*

6th Device*

Make - Model - GB Size - Color

6th Device Porting Number?*

Yes
No

6th Device Porting Phone Number*

6th Device BOYD (Bring Your Own Device)*

Yes
No

6th Device IMEI Number*

7th Device*

Make - Model - GB Size - Color

7th Device Porting Number?*

Yes
No

7th Device Porting Phone Number*

7th Device BOYD (Bring Your Own Device)*

Yes
No

7th Device IMEI Number*

8th Device*

Make - Model - GB Size - Color

8th Device Porting Number?*

Yes
No

8th Device Porting Phone Number*

8th Device BOYD (Bring Your Own Device)*

Yes
No

8th Device IMEI Number*

9th Device*

Make - Model - GB Size - Color

9th Device Porting Number?*

Yes
No

9th Device Porting Phone Number*

9th Device BOYD (Bring Your Own Device)*

Yes
No

9th Device IMEI Number*

10th Device*

Make - Model - GB Size - Color

10th Device Porting Number?*

Yes
No

10th Device Porting Phone Number*

10th Device BOYD (Bring Your Own Device)*

Yes
No

10th Device IMEI Number*

Previous Wireless Company Name*

Previous Wireless Company Account Number*

Previous Wireless Company Account Pin*

Does Customer Have DIRECTV*

DIRECTV Account Number*

Viasat Zip Code Look up

(Viasat) Data Package*

(Viasat) Unlisted Package*

(Viasat) Internet Speeds (Mbps)*

AT&T U-verse Availability

Internet Speeds (Mbps)*

Business Name*

Business Contact Name*

First Last

Business Contact Email*

Business Phone Number*

Business Service Address*

Street Address Address Line 2 City State ZIP Code

Is Billing Address Same as Service Address?*

Yes
No

Business Billing Address*

Street Address Address Line 2 City State ZIP Code

Customer Credit Card/Debt Card Number*

XXXX-XXXX-XXXX-XXXX

Customer Credit Card/Debt Card Expiration Date

XX-XX

Customer Credit Card/Debt Card CVC*

XXX

Auto-Pay*

Yes
No

Tax ID*

Type Of Viewing*

Public - any business that serves food and/or drinks (bars, restaurants, coffee shops)
Business - businesses that do not serve food or drinks and have TVs accessible to their customers (gyms, salons, waiting areas, auto shops)

Number of TVs*

Estimated Viewing Occupancy*

Please enter a number greater than or equal to 1.

Public Viewing Package*

Business Select Pack
Commercial Entertainment Pack
Commercial Xtra Pack

Public Viewing Package*

Business Select Pack
Commercial Choice Pack
Commercial Choice Plus Pack

Business Viewing Package*

Business Select Pack
Business Enterainment Pack
Business Xtra Pack

Does the Building Have a Flat Roof?*

No
Yes (a non-penetrating roof mount will be required for installation- there is an upfront fee of $100 for this)

Would They Like Any Sports Packages?*

Yes
No

Fire Code Occupancy*

Please enter a number greater than or equal to 1.

**The customer will be required to submit an approved Fire Code Occupancy certificate to DIRECTV prior to the activation of any premium sports package

Attach Fire Code Occupancy Certificate*

Accepted file types: iejpg, gif, png, pdf, Max. file size: 10 MB.

ADT Packages*

Traditional (Activation Fee $99)
Traditional w/ Life Safety (Activation Fee $99)
Remote (Activation Fee $99)
Video Lite (Activation Fee $99)
Control (Activation Fee $99)
Video Lite & Control (Activation Fee $199)

ADDITIONAL EQUIPMENT

Windstream Internet Speed*

Comcast/Xfinity

Select All
TV
Internet
Home Phone

Comcast/Xfinity TV Packages*

Comcast/Xfinity Internet Speed*

Comcast/Xfinity Home Phone*

New Number
Porting Number

Alder Packaging*

Additional Equipment & Pricing

Motion Detector ($2 additional monthly)
Smoke Detector ($2 additional monthly)
Glass Break Detector ($2 additional monthly)
Door/Window Sensor ($1 additional monthly)
Key Fob ($1 additional monthly)
Medical Pendant ($1 additional monthly)
Outdoor Camera ($4 additional monthly plus $50 on activation)
Indoor Camera ($2 additional monthly plus $25 on activation)

Frontier Internet Plans*

Basic Internet & Interent*

FiberOptic*

Internet Fixed Wireless*

Does Your Customer Want Frontier TV*

Yes
No

Frontier TV*

Whole Home DVR*

Yes
No

Set-Top Boxes Needed*

Notes/Comments

Name

This field is for validation purposes and should be left unchanged.

Enter Order Here

KR Communications Sales Form

Step 1 of 2