Blank Order Forms - Ground Floor Marketing

NEW DISH NETWORK CUSTOMER SALES ORDER WORKSHEET
Account Number
Sales Rep Name
Date
Install Date & Time
CUSTOMER INFORMATION
Customer Name
Email
Phone 1
Address
Phone 2
NUMBER OF TELEVISIONS & TYPES OF RECIEVERS
TV -1 Room
Hopper
TV -2 Room
Super Joey
TV -4 Room
Hopper
Hopper
Joey
TV -3 Room
Super Joey
Joey
TV -5 Room
Super Joey
Joey
Hopper
Hopper
Super Joey
Joey
Super Joey
Joey
TV -6 Room
Super Joey
Joey
Hopper
SELECT PACKAGE
Smart
Pack
America's
Top 120
America's
Top 120 +
Over 190 Channels
+ Regional Sports
$29.99
$19.99
Over 55 Channels
$34.99
America's
Top 200
$39.99
Over 240 Channels
ESTIMATE THE MONTHLY SERVICE TOTAL
America's
Everything
America's
Top 250
$44.99
Over 290 Channels
$91.99
Over 330 Channels
* America's
Everything
includes 4
Premium
Movie
NOTES
Number of Recievers
Base Programing Package _________________________
Advanced Reciever Service ($12 Hopper) Yes or No
$10 Super Joey Yes or No
Additonal Joey's ______ x $7 for each additonal box
Total Est Monthly Service Total with Bill Credit Offers
(Does not include taxes)
Months ________ through ___________
Months ________ through ___________
CUSTOMER QUALIFICATION AND PAYMENT INFORMATION
Social Security Number
Credit Card Number
Date of Birth
Expiration
TOTAL 1ST MONTH'S BILL CHARGED BEFORE INSTALL
CCV
SERVICE TERMS & CONDITIONS
__Credit Check
__Credit Card Requirment & Payment
upon Cancelation
__Installation & Custom Install Fees
__Landlord Approval prior to
Installation
__ 24-Month Agreement
__Early Cancellation Fee
*This worksheet is for order entry purposes only and is not your contract with Dish Network. Programming, pricing, terms and conditions subject to change at any time. Pricing residential.
Taxes not included. Reciept of Dish Network programming subject to Dish Network Customer Agreement.

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