Application Form

First Name Last Name M I

DEROS PhoneUnit

Signature Date

Type of Order

New CancellationModification

Subscriber Information

Mailing Address UNIT APO BOX ZIPAP Rank/Grade

Serving Address AptBldg

TV Service

Digital Basic (Must Rent HD STB $15.95)

Plus TV $52.45 ShowTime/TMC Channel $15.70

Starz!/Encore Premium Pack $12.08 High Definition Pack $4.95

Phone number

Email Address

TFC $11.95 GMA Combo $19.95 GMA Combo + TFC $27.95

First STB SD FREE

Additional SD $6.25 ________

Or First STB HD $6.95

Additional HD $15.95 ________

HD (Basic) $15.95 ______