DTV New Customer Registration Form

DTV and AT&T Generation Submission
Customer Information
Full Name *

Prefix First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Alternate Phone
E-mail

Confirmation Email example@example.com

Services customer currently using:
Hi, this is Jason with Nationwide TV and Internet providers, giving you a call in regards to the text message you received for TV services.

You were referred to us by your local installer to get you a superior package in terms of pricing and Quality every month.

Now, may I know who is your current service provider?
TV Service *
And How many TVs do you have?
No. of Tvs *
Do you mind me ask how much are you paying them?
TV Bill per month *
Internet Provider
Internet Bill per month
For some additional discounts and to make sure I am giving you the lowest rates possible, who is you cell phone provider?

You can get an additional $15 OFF of the Promotional Price i'm going to quote you.
Cellphone Provider *
Cellphone Bill per month

Products/Services Offered:
Now, I am not sure if you know this, AT&T bought out Direct a few years back so we should be able to get you tons of savings through Direct, OK?
TV and Internet *

DTV AT&T
No. of TVs *
TV Plan Offered *
TV Plan Price
HD Box Price
TV Box Cost
Discount in Price
Okay here we go, Your Year 2 price will be:
DTV Price Year 2
First Month
And your Year 1 price will be:
DTV Price Year 1

Agent Name and Alias *

Real Name Alias
Center Name *
Center Email
example@example.com
There is no installation, no activation so there is absolutely nothing you pay upfront.
For a limited time, we also have a promotion in which I can get you premiums like HBO, Starz, Showtime and Cinemax absolutely free for the first three months.

Now, can you grab a pen and paper to write down the details so there is no confusion.
My telephone number
Year One Price
Year two price
Free Installation/activation

Now, I can have the team scheduled for installation, what days’ work the best for you, is it going to be weekends or weekdays

So we have two time slots, one in the morning and one in the afternoon
Installation Date

Day Month Year
Date Hour Minutes AM/PM Option
Now, they do require to lock everything in just a valid payment method on file.

Number one is to of course locking your install date and your equipment.

Number two let’s say in 2 years, 3 years or 10 years whatever the case is, if you decide you want to cancel your service, that card on file is like their insurance policy to make sure they get the equipment back.

However, nothing is going to be charged on the card and it would not be set for auto bill.
Now, you have a choice of using visa, master or American express...
Which one would you like to use today?
Payment Type
Click here to Verify the Credit Card
Billing Address

Street Address

Street Address Line 2

City State

Zip Code
Account Number
Confirmation Number
You'd get an additional $5 off for setting up Auto Bill, Would you want to?
Auto Bill

Yes No
Auto Bill Year 1
Auto Bill Year 2
Auto Bill First month
Switched Name

Prefix First Name Middle Name Last Name
DOB *

Month Day Year
Date of Birth
Submission Status *
Is it processed, a generate lead or canceled lead?
Notes
Should be Empty:

DTV and AT&T Generation Submission