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 Claim Form Approval
America's Family Entertainment, Inc.
__________________________________
( Your Company Name)
Twelve Month Contract:____________________ Free Installation ______________
Customer Name:___________________________________________________________
Customer Address:_________________________________________________________
City:__________________________________________ State:_____________
Zip:______________
Telephone: (___)________________________________
Social Security # _______________________________
Credit Card # __________________________________
(All major credit cards accepted, no Debit cards)
Expiration Date
Month/Year___________/___________
Top 100/One Receiver at $36.99 p/mo. _______ or Two Receivers at $41.99 p/mo. _______ Top 150/One Receiver at $45.99 p/mo. _______ or Two Receivers at $50.99 p/mo. _______
Local Channels (where available) at $5.99 p/mo. _______ Promotion ___________________________________________________________________________
ROO # ___________________________________ SOO # ____________________________________
Customer Signature:________________________________________ Date: _____________________
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