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Submit this form and your DISH TV qualification results will appear instantly on the next screen.
First Name
Last Name
Primary Phone Number - -
Secondary Phone Number - -
Street Address Line (1)
(This must be the street address service will be installed at. No PO BOX.)
Street Address Line (2)
(examples: apt or unit numbers, lots, floors, etc ...)
City
State
Zip Code  (Five digits)
Do you own the residence?
Is your billing address the same?
Email Address
This is used to send a confirmation email. We will not SPAM you.
Order Notes:
info iconDISH requires your date of birth and social in order to qualify you for service. This form is encrypted (SSL/HTTPS) for security purposes. Your information is private and secure.
Date of Birth; /
Social Security Number - -
(This webpage is secured with state-of-the-art SSL encryption)
Answer this question, please: What is 5 + 1? Put answer in the box.
(Sorry for asking! Answering this questions prevents SPAM. The answer is 6.)
info iconCheck the terms and conditions box, then click the submit button, and you will be contact within 5 minutes (during our business hours). Clicking the submit button will display a review for you.
I have read, accept, and understand the Terms & Conditions
Submit:
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