FIRST NAME                                            MI                LAST NAME
 SOCIAL SECURITY NUMBER                   DRIVER'S LICENSE/ID #                  STATE
INSTALLATION ADDRESS, NO P.O. BOX        
             
CITY                                                      ST                 ZIP CODE
MAILING/BILLING ADDRESS (The address that bill should be sent to)
**This address must be the same as the address for the credit/debit card you will provide.**
CITY                                                      ST                   ZIP CODE
If you do not have an email address, we will submit the rebate on your behalf
Order confirmation & rebate instructions will be emailed to you from DIRECTV
EMAIL ADDRESS-required for immediate rebate submission
 RETYPE EMAIL ADDRESS
BEST TIME TO CALL to confirm order
PHONE NUMBER, INCLUDE AREA CODE
 PHONE NUMBER, INCLUDE AREA CODE
REQUIRED
 REQUIRED
REQUIRED
 REQUIRED
CVV CODE- 3 digits at end of signature line on
Discover, MC & Visa, or
4 digits on front of AMEX
I DO NOT want auto-pay setup & understand that I will
not receive FREE HD service.
PLEASE SIGN ME UP FOR AUTO-PAY USING THE
CREDIT/DEBIT CARD PROVIDED.
FREE HD with Choice Xtra & Higher
packages requires Auto-Bill Pay
SELECT Programming Package
RECEIVER 1
 R
E
C
EI
V
E
R
2
 R
E
C
EI
V
E
R
3
R
E
C
EI
V
E
R
4
      
             
             
             
       
Hold down "control" button to select more than 1 choice
The form below is a qualification for New Customers
Upon completion of this form, a customer sales rep will contact you to review your receiver selection, programming package and to answer any
questions you may have
All About Satellite
318-402-0269