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Your Name (required)

Your Email (required)

Phone Number

Street Address, City, State, Zip

Wireless
Current Provider

Number of Phones
Family Plan  Yes No
Months Left On Current Plan
Data Usage
Approximate Monthly Bill $

Telephone
Do you have a home or business phone?  Yes No
Is this with a home or business phone?  Home Business
Do you have more than one line?  Yes No
Current Provider

Bundled with:  TV Internet Both None
Bundle Total $
Do you have unlimited calling?  Yes No
International Calls  Yes No
Approximate Monthly Bill $

Internet
Current Provider

Bundled with  TV Phone Both None
Approximate Monthly Bill $

Television
Do you currently pay for TV?  Yes No
Current Provider

Number of receivers (TVs connected)
Do you have:  HDTV DVR Both None
Approximate Monthly Bill $

Security
Do you have a security system?  Yes No
Current Provider
Months left on contract
Approximate Monthly Bill $

Technical Support
Current Provider
Do you perform a regular backup of all your files?  Yes No
Have you ever dad a computer virus?  Yes No
Approximate Monthly Bill $

Energy
Current Electric Provider
Current Gas Provider
Do you have Solar Panels?  Yes No
Do you want Solar Panels?  Yes No
Average Electric bill
Average Gas bill

Merchant Services
Do you process credit cards?  Yes No
Current Provider
Months left on contract
Approximate Monthly Card Processing $

Your Message