
Genext TV \| Sign-Up Form
Please Choose Your Base Package To Begin
Television
Internet
Digital TV Options:
Digital Paks ($7/each) Channel Guide
Family	Sports	Latino
Movie Paks ($10/$10/$18 respectively) Channel Guide
GTV Pak	Encore/Starz	HBO/Cinemax
Select your Digital Services ($7/free/free) requires certain equipment
HDTV	DVR	Interactive Gaming
Digital TV Equipment:
Required Receiver
Extra Receiver			Quantity
Estimated Monthly Total
Personal Information:
First Name		Last Name
Company
Site Address		Billing Address
City		Zip Code
Home Location
Years at Address		Own or Rent
Phone		Alternate Phone
Employer		Work Phone
Drivers License		Date Of Birth

Reference		Reference Phone
Current Email
Referal
Internet & Television Account Information:
Please choose your email address and password (only applies to Internet Customers)
1st choice		Password
2nd choice		Password
Please indicate the number of TVs and PCs to be connected (see installation options below)
TVs in home		PCs in home
DVRs		High Def TVs
Computer Info
Internet & Television Installation Options:
Internet Installation
Internet Hardware
Computer Location
TV Installation
TV Hardware
	Total
Custom & Value Added Services: Genext offers both Custom and Value Added Services at discounted rates when work is performed during installation of your Genext TV and/or Internet Service. The following services require specialty technicians; therefore, they must be selected and scheduled in advance. When you select a Custom or Value Added Service, a Genext Systems Representative will contact you to discuss the details. Simply choose the services you are interested in and we will take care of the rest.
Please select any Custom Services
HDTV Wiring	Theatre Wiring	Speaker Wiring
Please select any Value Added Services
HDTV Setup	Program Remotes	Connect Your Theatre

Security Deposit & Billing Information: Digital Customers may elect to place a credit card (VISA or MasterCard) on file to be used as a security deposit. This card will not be charged unless, 1.) Customer requests monthly auto-pay, 2.) The account is in default (no or late payments), 3.) Genext Equipment is damaged or not returned. Refer to our policies for more information.
Unless otherwise indicated, Genext will provide a Credit Card Authorization form. We will need the authorization form prior to performing installation.
If you would rather make a $100.00 Cash or Check Deposit, Click This Box.

Billing Options
Other Email
Estimated Monthly*		Estimated Install*
Comments
* Estimated Monthly Fees do not include tax, franchise or IIS Services. (Typically, less than traditional cable companies.) Estimated Installation Fees are based on information provided at the time of sign-up. Please refer to our Installation Price Guide for details. Acceptance of Order: By selecting that you agree to the Terms & Conditions you are agreeing to Genext, LLC’s Terms & Conditions, Subscriber Agreement(s) and the associated Service Policies. Further, you are authorizing Genext to provision services at the address you’ve provided. Once services have been provisioned (order submitted with PUD) a minimum of one month service will be invoiced and due.
By selecting this box you hereby accept Genext, LLC’s Terms and Conditions and applicable Service Polices and Agreements.
Legal Policies \| Privacy Policy

Thank You! We will respond immediately to the email address you indicated with additional information, as well as the Credit Card Authorization Form. Please remember that we must receive the Credit Card Authorization Form no fewer than 48-hours prior to the scheduled installation date and time. We appreciate your cooperation and look forward to serving you.
Installation Date		Installation Time
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