Independent Retailer Form
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
The (tentative) name of my home business is:
I am interested in being an independent retailer for:
DIRECTV
Spectrum
Both
Yes, I understand that the first sale of respective service company is a qualifying sale and does not pay commission'
Yes, I understand that services for personal use are recommended for best practices but not required'
Yes, I understand that I am starting a home-based business as an independent contractor and intend to pursue business success
Yes, I understand that the first month of DIRECTV is free, the first 3 months of Showtime and MGM is free and the first bill is due in about 60 days as a DIRECTV Authorized Retailer
Yes, I consent to a one time $19.95 delivery and installation fee for DIRECTV equipment and a 24 month agreement of DIRECTV service with the BUSINESS XTRA package for at least the first 30 days to qualify as a DIRECTV Authorized Retailer
Yes, I understand that the first 12 months of Spectrum Mobile is free as Spectrum Authorized Retailer
Yes, I understand and agree that the Company will take all measures to protect the confidentiality of my Sensitive Information and will comply with all applicable data protection and privacy laws 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
Shipping Address
City
State
Zip Code
Billing Name
Billing Address
16 Digit Card Number
Expire Date :
CVV
Send
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