Residential Sign Up Form Account Name * Street Address Address 1 Address 2 City State/Province Zip/Postal Code Country Billing Address If different from Street Address Address 1 Address 2 City State/Province Zip/Postal Code Country Contact Phone * (###) ### #### Alternate Phone (###) ### #### Internet Speed Play * Fiber 100 ($75) Fiber 300 ($85) Fiber 500 ($105) Video Services PureHD TV ($70) DirecTV - Entertainment ($84.99) DirecTV - Choice ($99.99) DirecTV - Ultimate ($129.99) DirecTV - Premier ($174.99) Phone Services No Thanks Yes, add phone service ($29.99) Yes, add unlisted phone service (additional $7 per month) Do you Rent or Own? Rent Own Select Router Blast Max Router ($14.99) Blast Mini Router ($11.99) Wifi Mesh Units 1 ($4.99) 2 ($9.98) Contact's Name * First Name Last Name Email Thank you!
