$$$ Charter + All Providers Sales Order Form $$$:

Charter + All Providers Sales Order Form:

Please indicate in the Notes/Comments section of this order form as to which provider to RUN the customer with & which services they want. You should always go to BroadBandNow.com to find out which providers are available in the customers area. (This Order form is intended for Internal Office use only)
Customer Name*

First NameLast Name
E-mail*
Best contact# - Home/ Cell *

Area CodePhone Number
Service Address*

Street Address

Is this an Apartment or house? (MUST get Apt# or Lot#)

CityState

Zip Code
Billing address to the CC if different then Service Address:

Street Address

Is this an Apartment or house? (MUST get Apt# or Lot#)

CityState

Zip Code
Important: Which PROVIDER are you with & what SERVICES do you have NOW?*
List PROVIDER & SERVICES you have NOW?
Did you just move into the home & you're looking for Brand New Service? *

YESNO
Please select the Charter package you would like to order: *

Charter Triple Play - Select Bundle package (125 Channels) = $99.99 per moCharter Triple Play - Silver Bundle package = (175 Channels) = $119.97 per moCharter Triple Play - Gold Bundle package = (225 Channels) = $139.97 per moCable TV ONLY - Select (125 Channels) = $59.99 per moCable TV ONLY - Silver (175 Channels) = $79.99 per moCable TV ONLY - Gold (225 Channels) = $99.99 per moINTERNET ONLY (100mbps) = $44.99 per moUpgraded Ultra INTERNET (400mbps) = $44.99 + $25.00 extra per mo = Total = $69.99 per month
Would you like to add WIFI for $5 extra per month:*

YESNO
Would you like to add Premium Channels to your package:*

HBO = $15 per monthShowtime = $15.00 per monthCinemax = $15.00 per monthStarz = $15.00 per monthNO, I do not want any additional Premium channels
How many Cable Boxes do you need? Each HD Box is $6.99 each) (If the customer wants DVR service to 1 Box, the cost is an additional $12.99 per month / If the customer wants DVR service to 2-6 boxes, the cost is $19.99 per month)*

0123456
Tentative Installation Day (1st Preference Appt day - will call to confirm)*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Tentative Installation Time (1st Preference Appt time - will call to confirm)*

Morning from 8am - 12pmAfternoon from 12pm - 4 pm
One time Installation fee of $49.99 appearing on your 1st month bill. Activation fee is FREE*

I understand & agree.
Date of Birth:*

MonthDayYear
Example: 12-02-1980
ASK CUSTOMER: For security purposes, please select a 4 digit pin# as this will be used if you should contact Charter about your order in the future:*
4 digit PIN#:
ASK CUSTOMER: Security question= What is your favorite restaurant?*
Security Question:
Should you not get approved for this provider, Do we have your verbal permission to try & connect your service with other providers that may be available in your area?*
Type: YES or NO
Agents Name / Call Center:*
First & Last Name / Call Center:
Agents best contact#:*
Agents best contact#:
Agents Email address:*
Agents Email address:
Notes / Comments or additional instructions (Do Not Include customers sensitive info in the Notes below)
Should be Empty:

Charter + All Providers Sales Order Form: