Basic Video and Telephone

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Digital Cable and Internet Package

Contact Information

Name

Street Address

City

Zip

Email

Phone

Digital Cable Package Choice

Economy

10 MB 100 MB 200 MB 400 MB

Basic

10 MB 100 MB 200 MB 400 MB

Premium

10 MB 100 MB 200 MB 400 MB

1 GB

Yes, add to my 400MB package

1 GB

Yes, add to my 400MB package

1GB

Yes, add to my 400MB package

Would you like any Movie Channels?

HBO ($18.95) Cinemax ($17.95) Showtime ($15.95) Starz - Encore ($12.95) All Movie Channels ($52.95) No

Would you like Whole Home DVR Service? ($6.95)

Yes No

What type of set top box would you like?

How many set top boxes do you need?

Internet Options

Package Choice

100 MB 200 MB 400 MB

1 GB

Yes, add to my 400MB package

Would you like us to provide a Wireless Router?

Yes, with my install ($155.00) Yes, I will install myself ($100.00) No

Installation Preferences

Which day of the week works best for your install?

What time of day works best for your install?