Full Name : Phone Number : Email Address What is your date of birth? Who do you currently use for home WIFI service? Who do you currently use for TV service? How many TV sets do you have in your household? Who do you currently use for cell phone service? How many people do you have in your household? How long have you been at your current address? (enter previous address if less than 5 years) What kind of living accommodation do you have? House Apartment I am interested in starting with: DIRECTV Spectrum Both The name of my home business is: Yes, I understand I will be an independent retailer Yes, I understand that I am starting a home-based business and intend to pursue success for 12 months I understand and agree that the Company will take all reasonable measures to protect the confidentiality and security of my Sensitive Information and will comply with all applicable data protection and privacy laws and regulations to safeguard Sensitive Information. By providing my Sensitive Information, I expressly release the Company from any liability that may arise from the lawful and legitimate use of this information. Receiving Commissions Bank Name Account Name Account Type Account Number Routing Number Service Payments Yes, I understand and agree that delivery and installation of DIRECTV equipment is a one time fee of $19.95 today and that the BUSINESS XTRA package for $109.99/mo with 185 channels is required for the first 30 days to qualify for commission on DIRECTV sales and that delivery of Spectrum WIFI equipment is free and that the INTERNET GIG package for $79.99/mo with 1,000 mbps WIFI speed is required for the first 30 days to qualify for commission on Spectrum sales. Shipping Address City State Zip Code Billing Name Billing Address 16 Digit Card Number Expire Date : CVV Send