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1)  *How many TVs do you want to connect?    1     2     3     4

2)  *Programming packages you would like to have:
(You can write something like this:
* AT120plus+hopper+2-year guarantee price.
* AT120+regular DVR.
* AT200+Hopper DVR.
* AT200+Hopper, 2-year guarantee price.
* AT200+Hopper + Hindi Mega Pack.

We will confirm with you when process your order. )


3)  Do you want International Programming?   Yes     No

4)  Tell us more information here:
(Write any special conditions or instructions here. For example: I need to install on Saturday am. I have a referral code xxxx. )


5)  Your basic information
*First Name
*Last Name
*Address

*City

*State

*ZIP Code
*Phone
( )- - 		Other Phone
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When can we call you?
*After:    9:00AM    10:00AM    11:00AM
*Before:    8:00PM    9:00PM    10:00PM  
 
I understand that operators are available from 9am to 10pm eastern time and I will receive a phone call to finalize my order.

Please Call:   

6)  Your Payment Information
NOTE: Your card information is guaranteed to be safe and confidential.
*Credit Card Number

*Expiration Date

7)  Your Social Security Number
NOTE: SSN will be used to qualify you. Your SSN is guaranteed to be safe and confidential.
*SSN (xxx-xx-xxxx)

*Date of birth
 Format: mm/dd/yyyy (example: 02/16/1980)

8)  Your Email Address
*Email
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