FastGem Sales Form
Service
Type of Sale
(*)
Residential
Commercial
Invalid Input
Type of Viewing
(*)
Public- any business that serves food and/or drinks (bars, restaurants, coffee shops)
Business- businesses that do not service food/drinks and have TVs accessible to their customers (gyms, salons, waiting areas, auto shops)
Viewing Type Selection required!
Does the building have a flat roof?
Yes
No
Invalid Input
A non-penetrating roof mount will be required for installation. There is an upfront fee of $100 for this.
(*)
DIRECTV
AT&T Mobility
Viasat
AT&T U-verse
AT&T TV
ADT
Spectrum
Frontier
Windstream
Comcast/Xfinity
You must select a Service Provider!
AT&T U-Verse Availability
Viasat Zip Code Lookup
U-Verse Products
(*)
Triple Play (TV, Internet, & Phone)
Double Play (TV & Internet)
Double Play (Internet & Phone)
Single Play (TV)
Single Play (Internet)
You must select a product for the selected provider!
Comcast/Xfinity
(*)
Select All
TV
Internet
Home Phone
You must select a product for the selected provider!
Business Contact Information
Customer
Business Name
Invalid Input
First
(*)
First Name required
Customer Phone Number
(*)
Must be a 10 digit phone number XXX-XXX-XXXX
Alternate Phone Number
Invalid Input
Service Address
(*)
Address Required
Address Line 2
Invalid Input
City
(*)
Invalid Input
State
(*)
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
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Zip Code
(*)
Must be 5 digit zip
Customer Email
(*)
Must be a valid email address
Last
(*)
Last Name Required
Date of Birth
(*)
You must select a valid Date of Birth!
Social Security Number
(*)
This is a required field!
DL/ID Number
(*)
You must enter a valid DL/ID Number!
Driver License/ID State Issued
(*)
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
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DL/ID Expiration
(*)
You must select a valid DL/ID Expiration Date!
Is Billing Address Same as Service Address?
(*)
Yes
No
You must select 'Yes' or 'No'
Billing Service Address
(*)
You must provide a billing address, when 'Yes' selected for 'Is Billing Address the same..?'
Address Line 2 (optional)
Invalid Input
City
(*)
You must input a state for billing address.
State
(*)
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VA
VI
VT
WA
WI
WV
WY
Invalid Input
Zipcode
(*)
You must input a 5 digit zipcode!
Auto-Pay?
(*)
Yes
No
Selection Required!
Is Payment information needed?
(*)
Yes
No
Selection Required!
Tax ID
(*)
Tax ID number required!
Name on Card
(*)
Credit/Debit Card Name required!
Customer Credit/Debit Card Number
(*)
Please enter a valid CC/Debit Number!
Customer Credit/Debit Card Expiration Date
(*)
Please enter a valid Expiration Date!
Customer Credit/Debit Card CVC
(*)
CC/Debit Card CVC required!
Card Zipcode
(*)
You must input a 5 digit zipcode!
Attach Additional Documentation (If needed)
Invalid Input
DIRECTV Package
(*)
You must select a DTV Package when DTV is a selected Provider!
Number of TV's
(*)
1 TV
2 TVs
3 TVs
4 TVs
5 TVs
6 TVs
A selection is required!
Estimated Viewing Occupancy (Must be greater than or equal to '1')
(*)
Selection is required!
Business Viewing Package
(*)
Selection is required!
Would they like any sports package?
(*)
Yes
No
Selection is Required!
Viasat Data Package
(*)
Make a selection!
Viasat Internet Speeds (Mbps)
(*)
Viasat Unlisted Package
(*)
Make a selection!
U-Verse TV Package
(*)
U-Basic (15+ Channels)
U-Family (180+ Channels)
U-200 TV (360+ Channels)
U-300 TV (470+ Channels)
U-450 TV (550+ Channels)
This is a required field!
AT&T Internet Package
(*)
At&t Internet up to 100 MBPS (Standalone) $70
At&t Internet up to 300 MBPS (Standalone) $90
At&t Internet 1000 MBPS (Standalone) $110
Internet Selection Required!
U-verse Phone
(*)
Field is required!
Home Phone Number to be Ported?
(*)
Yes
No
Enter the phone # to be ported!
Name on Previous Home Phone Account
(*)
Invalid Input
Address on Previous Home Phone Account
(*)
Company Name of Previous Home Phone Account
(*)
Last Name Required
Previous Home Phone Account Number
(*)
Field is required!
Previous Home Phone Account Pin
(*)
Required field!
AT&T TV Packages
(*)
AT&T TV Xtra (235+ Channels) $64.99
This is a required field!
Number of Boxes
(*)
1 (Free)
2 ($120 Paid in Full at POS or $10 for 12 months)
3 ($240 Paid in Full at POS or $20 for 12 months)
4 ($360 Paid in Full at POS or $30 for 12 months)
5 ($480 Paid in Full at POS or $40 for 12 months)
6 ($600 Paid in Full at POS or $50 for 12 months)
Required Field!
ADT Packages
(*)
You must select a Package
Additional Equipment
(Please enter additional equipment in the 'Notes' section.
Spectrum Packages
(*)
Spectrum Triple Play (Starting at) $69.99
Spectrum Double Play (Starting at) $59.98
Spectrum Internet Only (Starting at) $44.98
Spectrum TV Only (Starting at) $29.99
Spectrum Internet; () $0
Spectrum Internet Ultra; () $0
Spectrum Internet Gig; () $0
Spectrum TV Select; () $0
Spectrum TV Essentials; () $0
Spectrum Mobile () $0
Spectrum TV Select; Spectrum Internet; () $0
Spectrum TV Select; Spectrum Internet Ultra; () $0
Spectrum TV Select; Spectrum Internet Gig; () $0
Spectrum Internet; Spectrum TV Essentials; () $0
Spectrum Internet Ultra; Spectrum TV Essentials; () $0
Spectrum Internet Gig; Spectrum TV Essentials; () $0
Spectrum Internet; Spectrum Voice; () $0
Spectrum Internet Ultra;Spectrum Voice; () $0
Spectrum Internet Gig;Spectrum Voice; () $0
Spectrum TV Essentials;Spectrum Voice; () $0
Spectrum TV Select; Spectrum Voice; () $0
Spectrum Internet/Spectrum Mobile () $0
Spectrum Internet Ultra/Spectrum Mobile () $0
Spectrum Internet Gig/Spectrum Mobile () $0
Internet-SPP Spectrum Internet,Video-SPP Choice 15,Voice () $0
Spectrum TV Essentials; Spectrum Internet Ultra; Spectrum Voice; () $0
Spectrum TV Essentials;Spectrum Voice;Spectrum internet Gig; () $0
Spectrum Mobile/Spectrum Voice/Spectrum Internet () $0
Spectrum Mobile/Spectrum Voice/Spectrum internet Ultra () $0
Spectrum Mobile/Spectrum Voice/Spectrum internet Gig () $0
Spectrum TV Select; Spectrum Internet; Spectrum Voice; () $0
Spectrum TV Select; Spectrum Voice; Spectrum Internet Ultra; () $0
Spectrum Internet Gig; Spectrum TV Select; Spectrum Voice; () $0
TV Essentials/Spectrum Voice/Spectrum Internet/Mobile (Quad Play Mobile) $0
TV Essentials/Voice/Spectrum internet Ultra/Mobile (Quad Play Mobile) $0
TV Essentials/Voice/Spectrum internet Gig/Mobile (Quad Play Mobile) $0
TV Select/Voice/Spectrum Internet/Mobile (Quad Play Mobile) $0
TV Select/Voice/Spectrum internet Ultra/Mobile (Quad Play Mobile) $0
TV Select/Voice/Spectrum Internet Gig/Mobile (Quad Play Mobile) $0
Spectrum Internet; () $0
Spectrum Internet 100; () $0
Spectrum Internet; Spectrum TV Select; () $0
TV Choice; () $0
Spectrum Internet; TV Choice; () $0
Spectrum Internet 100; Spectrum TV Select; () $0
Spectrum TV Select; Spectrum Internet Assist; () $0
Spectrum Internet Ultra; Spectrum TV Select; () $0
Spectrum Mi Plan Latino; Spectrum Internet; () $0
TV Choice; Spectrum Internet Ultra; Spectrum Voice; () $0
Spectrum Internet Gig; Spectrum TV Select; () $0
Spectrum Voice; () $0
Spectrum Internet 100; Spectrum TV Essentials; () $0
Spectrum Internet 100; Spectrum Voice; Spectrum TV Select; () $0
Spectrum Internet Assist; () $0
Spectrum Internet Assist; Spectrum TV Essentials; () $0
Spectrum Internet Assist; Spectrum TV Select; () $0
Spectrum Internet Gig; Spectrum Voice; Spectrum TV Select; () $0
Spectrum Internet; Spectrum TV Select; Spectrum Voice; () $0
Spectrum Internet; Spectrum Voice; TV Choice; () $0
Spectrum Mi Plan Latino; () $0
Spectrum TV Essentials; Spectrum Internet; () $0
Spectrum TV Select; Spectrum Voice; Spectrum Internet; () $0
Spectrum Voice; Spectrum Internet 100; () $0
Spectrum Voice; Spectrum Internet 100; Spectrum TV Select; () $0
Spectrum Voice; Spectrum Internet Gig; () $0
Spectrum Voice; Spectrum Internet Gig; Spectrum TV Select; () $0
Spectrum Voice; Spectrum Internet Ultra; () $0
Spectrum Voice; Spectrum Internet Ultra; Spectrum TV Essentials; () $0
Spectrum Voice; Spectrum Internet Ultra; Spectrum TV Select; () $0
Spectrum Voice; Spectrum Internet; () $0
Spectrum Voice; Spectrum Internet; Spectrum TV Essentials; () $0
Spectrum Voice; Spectrum Internet; Spectrum TV Select; () $0
Spectrum Voice; Spectrum TV Essentials; Spectrum Internet; () $0
Spectrum Voice; Spectrum TV Select; Spectrum Internet Ultra; () $0
Spectrum Voice; Spectrum TV Select; Spectrum Internet; () $0
TV Choice; Spectrum Internet; Spectrum Voice; () $0
Spectrum TV Select; Spectrum Internet 100; Spectrum Voice; () $0
Spectrum TV Select; Spectrum Internet Gig; Spectrum Voice; () $0
Spectrum TV Essentials; Spectrum Internet Ultra; () $0
TV Choice; Spectrum Internet 100; () $0
Video-SPP Select () $0
Spectrum TV Select; Spectrum Internet 100; () $0
Spectrum Internet Gig; Spectrum Voice; () $0
Spectrum Internet; Spectrum Mi Plan Latino; () $0
Spectrum TV Essentials; Spectrum Internet 100; () $0
Spectrum Internet 100; Spectrum Voice; () $0
Spectrum TV Essentials; Spectrum Internet 100; Spectrum Voice; () $0
Spectrum Voice; Spectrum TV Select; () $0
Internet-SPP Ultra () $0
Internet-SPP Gig () $0
Internet-SPP Internet 50/100 () $0
Internet-SPP Spectrum Internet () $0
Internet-SPP Internet Assist () $0
Internet-SPP Gig,Video-SPP Select () $0
Internet-SPP Internet 50/100,Video-SPP Select () $0
Internet-SPP Internet Assist,Video-SPP Select () $0
Internet-SPP Spectrum Internet,Video-SPP Select () $0
Internet-SPP Ultra,Video-SPP Select () $0
Internet-SPP Ultra,Voice () $0
Internet-SPP Gig,Voice () $0
Internet-SPP Internet 50/100,Voice () $0
Internet-SPP Internet Assist,Voice () $0
Internet-SPP Spectrum Internet,Voice () $0
Internet-SPP Gig,Video-SPP Choice 15 () $0
Internet-SPP Internet 50/100,Video-Spectrum TV Essentials () $0
Internet-SPP Internet Assist,Video-Spectrum TV Essentials () $0
Internet-SPP Spectrum Internet,Video-SPP Choice 15 () $0
Internet-SPP Ultra,Video-SPP Choice 15 () $0
Video-SPP Select,Voice () $0
Video-SPP Choice 15,Voice () $0
Internet-SPP Spectrum Internet,Mobile () $0
Internet-SPP Gig,Mobile () $0
Internet-SPP Ultra,Mobile () $0
Mobile () $0
Video-SPP Choice 15 () $0
Internet-SPP Gig,Video-SPP Choice 15,Voice () $0
Internet-SPP Ultra,Video-SPP Choice 15,Voice () $0
Internet-SPP Spectrum Internet,Video-SPP Select,Voice () $0
Internet-SPP Gig,Video-SPP Select,Voice () $0
Internet-SPP Ultra,Video-SPP Select,Voice () $0
Internet-SPP Spectrum Internet,Video-SPP Choice 15,Voice () $0
Internet-SPP Spectrum Internet,Video-SPP Choice 15,Voice () $0
Internet-SPP Spectrum Internet,Video-SPP Select,Mobile () $0
Internet-SPP Ultra,Mobile 2 () $0
Internet-SPP Gig,Mobile 2 () $0
Internet-SPP Spectrum Internet,Mobile 2 () $0
Mobile 2 () $0
Package Selection Required!
Will Home Phone Service be included?
(*)
Yes
No
You must select Yes or No
Spectrum Home Phone
(*)
New Number
Porting Number
This is a required field!
Home Phone Porting Number
(*)
Invalid Input
Current Company Porting Number Name
(*)
Last Name Required
Current Company Porting Number Account Number
(*)
Required Field!
Frontier Internet Speed (Mbps)
(*)
Windstream Internet Speed
(*)
This is a required field!
Comcast/Xfinity TV Packages
(*)
Field Required!
Comcast/Xfinity Internet Speed
(*)
This is a required field!
Comcast/Xfinity Home Phone
(*)
New Number
Porting Number
This is a required field.
Home Phone Porting Number
(*)
Invalid Input
Current Company Porting Number Name
(*)
Last Name Required
Current Company Porting Number Account Number
(*)
You must fill out this field!
Fire Code Occupancy (Must be greater than or equal to '1')
(*)
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.
Attach Fire Code Occupancy Certificate
(*)
You must attach a Fire Code Certificate!
Data Package
(*)
AT&T Unlimited & More Premium Plan
AT&T Unlimited Extra Plan
AT&T Unlimited Starter Plan
Other
Data Selection Required!
Upgrade Frequency
(*)
AT&T Installment Plan with Next Up
AT&T Installment Plan
Selection required!
Does Customer Have DIRECTV?
(*)
Yes
No
Selection is required!
DIRECTV Account Number
Number of Lines
(*)
0
1
2
3
4
5
6
7
8
9
10
Selection required!
1st Device Porting Number?
(*)
Yes
No
Selection required!
1st Device Porting Phone Number
(*)
Selection required!
2nd Device Porting Phone Number
(*)
Yes
No
Selection required!
2nd Device Porting Phone Number
(*)
Selection required!
3rd Device Porting Number
(*)
Yes
No
Selection required!
3rd Device Porting Phone Number
(*)
Selection required!
4th Device Porting Number
(*)
Yes
No
!
4th Device Porting Phone Number
(*)
!
5th Device Porting Number?
(*)
Yes
No
!
5th Device Porting Phone Number
(*)
!
6th Device Porting Number?
(*)
Yes
No
!
6th Device Porting Phone Number
(*)
Invalid Input
7th Device Porting Number?
(*)
Yes
No
!
7th Device Porting Phone Number
(*)
Invalid Input
8th Device Porting Number?
(*)
Yes
No
!
8th Device Porting Phone Number
(*)
!
9th Device Porting Number?
(*)
Yes
No
!
9th Device Porting Phone Number
(*)
!
10th Device Porting Number?
(*)
Yes
No
!
10th Device Porting Phone Number
(*)
!
Previous Wireless Company Name
(*)
First Name required
Previous Wireless Account Number
(*)
Must be a 10 digit phone number XXX-XXX-XXXX
Previous Wireless Company Account Pin
(*)
Must be a valid email address
1st Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
1st Device IMEI Number
(*)
!
1st Device (Make-Model-GB Size-Color)
(*)
!
2nd Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
2nd Device IMEI Number
(*)
!
2nd Device (Make-Model-GB Size-Color)
(*)
!
3rd Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
3rd Device IMEI Number
(*)
!
3rd Device (Make-Model-GB Size-Color)
(*)
!
4th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
4th Device IMEI Number
(*)
!
4th Device (Make-Model-GB Size-Color)
(*)
!
5th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
5th Device IMEI Number
(*)
!
5th Device (Make-Model-GB Size-Color)
(*)
!
6th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
6th Device IMEI Number
(*)
!
6th Device (Make-Model-GB Size-Color)
(*)
!
7th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
7th Device IMEI Number
(*)
!
7th Device (Make-Model-GB Size-Color)
(*)
Invalid Input
8th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
8th Device IMEI Number
(*)
!
8th Device (Make-Model-GB Size-Color)
(*)
!
9th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
9th Device IMEI Number
(*)
!
9th Device (Make-Model-GB Size-Color)
(*)
!
10th Device BYOD (Bring Your Own Device)
(*)
Yes
No
!
10th Device IMEI Number
(*)
!
10th Device (Make-Model-GB Size-Color)
(*)
!
Notes/Comments
Notes/Comments
Invalid Input
Submit