subject_line
Team Name
Agent Name
*
Agent's eMail Address
*
Director's Email (optional)
Provider's Name
*
Charter
Comcast
DirecTV
AT&T
Vonage
Reliant
Ameritect
Account Number:
*
Account Holder's Information
Install Date is: (must be at least 3 weeks out - no later than 5 weeks to do a claim)
*
+
I have confirmed by calling customer and found out they were installed on install date and are happy.
*
YES
NO
First Name:
*
Last Name:
*
Address line 1:
*
Address Line 2: (Apt, Lot, etc)
City:
*
State:
*
Zip Code:
*
Phone Number:
*
eMail Address:
*
Special Notes: (Services customer signed up for)
*
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