DIRECT TV REFERRAL FORM

DIRECT TV REFERRAL SUBMISSIONS

SALES PERSON CONTACT INFORMATION

* Indicates required field

First and Last Name of Sales Rep (Person Submitting) *

First

Last

Submitter's Email *

Submitter's Assigned WNE Dealer # *

Submitter's Name of Business *

Submitter's Phone Number *

POTENTIAL DIRECT TV CUSTOMER COMPANY INFORMATION

BUSINESS NAME *

Contact Name *

BUSINESS MAIN TELEPHONE NUMBER (BTN) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

BILLING ADDRESS IF DIFFERENT *

Line 1

Line 2

City

State

Zip Code

Country

Email *

NUMBER OF LANDLINES (POTS LINES) *

INCORPORATION DATE AND STATE *

EIN NUMBER *

SHARE IF EXISTING AT&T BUSINESS CUSTOMER *

If Yes, provide AT&T Customer Business Account Number (BAN) *

Are Current Phones POTS or VOIP? *

If Not DIRECT TV, Who Is Current Phone Provider? *

Best Contact Telephone Number *

Number of Pots Lines (Land Lines) *

Number of Fax Lines *

Fax Number *

Main Phone Number *

Phone Number *

List Additional Phone Numbers *

Comments *

Bill (Upload if available)

Upload File *

Max file size: 20MB

Upload file

Upload File *

Max file size: 20MB

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