Dish Network

1. Are you a homeowner?	Yes No
2. Are you interested in getting a Dish Network System installed in the next 30 days?	Yes No
3. Do you currently have or have had Dish Network?	Yes No
4. Do you have a valid major credit card?	Yes No

First Name:		Last Name:
Address:		City:
State:		Zip Code:
Day Phone:	( ) -	Home Phone:	( ) -
Email Address:		Yes, I want to be contacted within 24-48 hours.

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