Qualified Technology Entertainment DirecTV New Order Form Consultant Name Bryan Donoho John Smith Cathy Jones Other Consultant Name Current Monthly Entertainment Bill Total Monthly Cost Personal Information First Name Last Name Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Email Address Home Telephone Cell Number Social Security Number DO NOT ENTER REAL INFO NOT SECURE This form is under development and not intended for actual data. Please do not enter real information. Programming Packages Select a Programming Package Select Entertainment Choice Choice Xtra Ultimate Premier Package Add Ons Select Package Add Ons Sports Pack HD Pack Movie Pack International Pack Sports Packs Sports Extras MLB Extra Innings NBA League NHL Center Ice NFL Sunday Ticket NFL Sunday Ticket MAX HD Extra Pack HD Extra Pack 9 HD Channels Movie Pack Movie Entertainment Pack HBO Cinemax Showtime Starz International Programming International Programming Vietnamese Chinese Russian Brazillian Filipino Korean Protection Plan Yes No Monthly Price Your savings today Submit Δ
