FastGem Sales Form

Service

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Viewing Type Selection required!
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A non-penetrating roof mount will be required for installation. There is an upfront fee of $100 for this.
You must select a Service Provider!
You must select a product for the selected provider!
You must select a product for the selected provider!

Business Contact Information

Customer

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First Name required
Must be a 10 digit phone number XXX-XXX-XXXX
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Address Required
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Must be 5 digit zip
Must be a valid email address
Last Name Required
You must select a valid Date of Birth!
This is a required field!
You must enter a valid DL/ID Number!
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You must select a valid DL/ID Expiration Date!
You must select 'Yes' or 'No'
You must provide a billing address, when 'Yes' selected for 'Is Billing Address the same..?'
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You must input a state for billing address.
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You must input a 5 digit zipcode!
Selection Required!
Selection Required!
Tax ID number required!
Credit/Debit Card Name required!
Please enter a valid CC/Debit Number!
Please enter a valid Expiration Date!
CC/Debit Card CVC required!
You must input a 5 digit zipcode!

Attach Additional Documentation (If needed)

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You must select a DTV Package when DTV is a selected Provider!
A selection is required!
Selection is required!
Selection is required!
Selection is Required!
Make a selection!
Make a selection!
This is a required field!
Internet Selection Required!
Field is required!
Enter the phone # to be ported!
This is a required field!
Required Field!
You must select a Package

Additional Equipment
(Please enter additional equipment in the 'Notes' section.

Package Selection Required!
You must select Yes or No
This is a required field!
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This is a required field!
Field Required!
This is a required field!
This is a required field.
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Selection is required!
*The customer will be required to submit an approved Fire Code Occupancy certificate to DIRECTV prior to the activation of any premium sports package. 
You must attach a Fire Code Certificate!
Data Selection Required!
Selection required!
Selection is required!
Selection required!
Selection required!
Selection required!
Selection required!
Selection required!
Selection required!
Selection required!
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First Name required
Must be a valid email address
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Notes/Comments

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