Customer ID Sales Representative Install

Account #: NAME: Date:

q New q Existing PHONE: Time:

CUSTOMER INFORMATION
Legal Name Phone Mobile
Physical Address Billing
Address City
State/ZIP
Social Security # Email Birthdate ____ / ____
Credit Card # EXP CVV Visa MC Discover

Lead Information
1) Interested in - qNew service qUpgrading service qSwitching service
2) Current TV service provider - qCable qDirecTV qDish Network qOther ______________
3) Length of time with current TV service provider - _________
4) Monthly bill amount - $_______
5) Current setup - Total number of TVs _______ Number of HD TVs ______ Number of DVRs ______
6) Interests - qSports qMovies q$Value qChannel selection qOther __________________
7) Other service needs - qPhone qInternet
By completing this form I verify that the information contained herein is correct. I also give Groove Notes:
Satellite and its affiliates permission to contact me via telephone regarding Groove Satellite’s prod-
ucts, services and promotions. Groove Satellite will use this information for internal purposes
only and will not share or sell this information to any third party.

Signature X __________________
DIRECTV EQUIPMENT Notes:
1 2 3 4 5
STD STD STD STD STD ($75)
DVR ($99) DVR ($99) DVR ($99) DVR ($99) DVR ($99)
HD ($99) HD ($99) HD ($99) HD ($99) HD ($99) Equipment Subtotal $
HD DVR($199) HD DVR($199) HD DVR($199) HD DVR($199) HD DVR($199) INSTANT REBATE (free primary receiver)
DVR or HD = ($99) HDDVR = ($199) $ (99) / (199)
$_________ $_________ $_________ $_________ $_________
TOTAL EQUIPMENT FEES
DVR Declined (initial) HD Equip Declined (initial) due at activation (does not include tax) $
PROGRAMMING Additional Fees Upgrades
q Family - 45+ (always $29.99) q HD Access ($10) q TV Mirror ($45) q Tripod ($75)
q Choice - 150+ ($55.99) q DVR fee ($6 / acct) q Dish Heater ($150) q SWM upgrade HD ($45)
q Choice Xtra - 200+ ($60.99) q Additional receiver q Wall Fish (varies) q Phonex ($75/room)
q Plus DVR - 200+ ($65.99) $5 x ___ = $_____ q OTA Antenna ($110) q Ethernet adapter ($150)
q Plus HDDVR - 200+ ($75.99) q RF Remote ($40) additional rooms - $75 ea.
Movie Channels
q Premier - 265+ ($109.99) q IR Remote ($30)
q HBO $15
q Optimo Mas - 150+ ($44.99) Premium Channels Upgrade Subtotal $
q STARZ $13
q Optimo MasPlus- ($49.99) q Showtime (free for 6 mo.) $13 q ESPN Full Court (TBD) q MLB Extra Innings (TBD)
q Mas Ultra - 210+ ($57.99) q Cinemax $13 q ESPN Game Plan (TBD) q Nascar HotPass (TBD)
q Lo Maximo - 275+ ($109.99) q Sports Pack $13 q NFL Sunday Ticket ($59.99/mth) q NBA League Pass (TBD)
q International: ____________ q NFL SuperFan ($20/mth) qAutopay
Total ___________ Total ___________ Total ___________ Total Monthly Rate $
Equipment and Activation Total Monthly Service Total
Equipment/Upgrades Costs (tax not included) $ Satellite Monthly Rate (tax not included) $
Activation Fee $ 100.00 12 month DirecTV package rebate $ (16.00)
Total Fees Due at Installation $ 12 Month DirecTV email rebate $ (5.00)
Satellite Monthy Rate (promo) (tax not included) $
By initialing, I acknowledge that my DirecTV
service carries a 24 month agreement

1(866) 998-0192 www.GETGROOVEN.com

v 1.1
 DirecTV Rebate Process

Customer Online Redemption Process

• Visit directv.com/rebate to set up an account or log-in to existing account to redeem.

• Click “Rebate Redemption” link
• Validation email is sent to customer address.
• Validate email address
• Click validation link within email.
• Customer is redirected to directv.com/rebate to complete process.
• Complete rebate
• Rebate form is pre-populated with customer information.
• Click submit.
• Customers eligible for additional $5 rebate will be prompted to provide email consent if they have
not already to complete process online.
(Tip: IF customer eligible for additional $5 rebate does not provide email consent, they MUST mail in their rebate form.)
• All customers will receive a redemption form with their first bill outlining the monthly discounts.
Customers eligible to submit online should NOT mail in the redemption form.
• Online rebate will be processed within 6-8 weeks.

Customer Mail-In Redemption Process

• Customers unable to create a directv.com account and provide their email

(and consent if eligible for additional $5/mo. rebate) are required to submit by mail
• Mail-in the rebate form included with the first bill.
• Mail-in rebate will be processed within 8-12 weeks.

Customer Rebate Tips

• To check rebate status, visit directv.com/rebate or call 1-877-286-4808

• Rebate must be submitted online or via mail within 60 days of account activation.
• Redemption form should NOT be mailed with payment.
• Dealers/customer service cannot submit rebate of behalf of a customer.