Questionnaire

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Landline phone
Current Provider
Phone number
Landline &/or Mobile line
Monthly bill amount /mo.
Mobile
Current provider
Phone number
Current brand mobile phone
# of phones on current plan
Amount of minutes in your plan /mo.
Amount of data/text messages in your plan /mo.
Contract expiration date
Monthly bill amount /mo.
Security system
Do you currently have a security system?
- Yes
- No
Current provider
Months left under contract mos.
Monthly bill amount /mo.
Energy bill
Current electric provider/supplier
Current gas provider/supplier
Monthly gas bill amount /mo.
Monthly electric bill amount /mo.
Internet
Current provider
High speed internet
Bundled with phone or TV
- Yes
- No
Monthly bill amount /mo.
Credit Card Processing
Current provider
Monthly bill amount
TV/Direct (conference room/patient room)
Current provider
# of receivers
Monthly bill amount /mo.

Landline phone