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Application Form

Fax Back if you prefer at: (305) 687- 1279

Important Note: " We suggest you Print and fax this application because the confidential information. In order to print just print the page from your browser or in order to download in Microsoft Word click here:

Physical Address

If the customer selects programming combinations requiring four or more orbital locations, more than one receiver is required to view all programming. During installation, customers will need to decide which programming they prefer to watch on which receiver (up to three orbital locations per receiver).

SERVICE ADDRESS
* First Name		* Last Name

* Address Line 1

Address Line 2

* City	* State	* Zip Code

* Service Address Phone Number - -		Business/Day Phone Number - -
Email Address
Check this box if your billing address is the same as the service address

BILLING ADDRESS

* Address Line 1

Address Line 2

* City	* State	* Zip Code

SS:

Credit Card : Exp Date

How many equipments High Definition with DVR ? ( Max free only 1)

How many equipments High Definition (with NO DVR)? ( Max free only 1)

How many equipments Regular Box? ( Max free only 4)

Note: The free equipments are included if the client’s credit is approved.

Combination of Equipments included and extra equipment:

1) Included at no charge is One box High definition with DVR and One regular Box.___

2) Or Included at no charge are four regular boxes ___

3) Or Included at no charge 1 High Definition Box ( NO DVR included) ___

4) If the client wants One High definition with DVR plus One High Definition box (with no DVR) extra charge $125 will be charged.____

5) If the client wants two Hi definitions Box with DVR the first one is at no charge the second one is at $490.____

Disclosure Note:

The installer will collect on site a charge of $49.99 at the moment of the installation; Dish network will return to the client in the first bill as a credit the amount of $49.99 All this information will generate a contract that will be send to the client to be signed and returned to the retailer fax (305) 687 1279.

Select the Type of Service the client wants: 100% digital packages

America’s Top 100 32.99/mo ………................................................. ( See brochure attached)

America’s Top 200 $44.99/mo ………………………………………… ( See brochure attached)

America’s Top 250 $54.99/mo ………………………………………… ( See brochure attached)

America’s “Everything” pack $94.98/mo ……………………………… ( See brochure attached)

Multi Sports Packages $ 5.99 /mo :

Super stations: Ktla-kwgn-wsbk-wpix-wwor $5.99

A La Carte

BabyFirstTV 9.99/mo

Bloomberg Television $1.50/mo

The out door channel $ 1.99/mo

If you need any special Channel around the world call to check availability

(Telephone to call for information is the retailer GCS Inc. ( 305) 673-3879)

Client Signature_______________________________

Date of application:_____________________________

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