ACN

Thank you for your interest in the ACN Opportunity. You've taken a very important first step toward changing your life... and the course of your future forever. Complete the fields below and I will be in contact with you soon.

Contact Information

Name: *

Phone:

 

Please use this format: (999-999-9999)

Email: *

Verify Email: *

How do you prefer to be contacted?

Phone E-mail

When is the best time to reach you?

Morning Afternoon Evening

Your Interest: *



Validation phrase: *

Comments

So I can recommend the best services for your needs, please fill out additional information on your current home services or those you are interested in adding.

  
 
  |  
 

What Country do you live in?

United States Canada
Address

City:

State:    Zip Code:
Address

City:

Province:    Postal Code:

 

I currently Own Rent

1. Digital Phone Service with Video Phone

 

Do you call anyone who you wish you could see more often?
I am interested in Digital Phone Service (Unlimited Calling)

2. Local/Long Distance Service

Current Provider:

Primary Phone Number:

(xxx-xxx-xxxx)

My monthly bill is approximately:

$

Bundled with:

TV Wireless Internet All None

Total Bundled Bill:

$

International Calls:

Yes No

Long Distance:

Yes No

I am interested in Unlimited Calling:

Yes No

3. Internet Service

Current Provider:

My monthly bill is approximately:

$

Bundled with:

TV Wireless All None

Total Bundled Bill:

$

Type of Service:

Cable
DSL
Dial-Up
Wireless Aircard (Provider: )

4. Home Security & Automation Service

Current Provider:

My monthly bill is approximately:

$

 

I do not have home security service today, but I am interested in more information.

 

I am interested in Home Automation service.

5. Wireless Service

Current Provider:

 

I love my current provider
I am open to using a different provider

My monthly bill is approximately:

$

Bundled with:

TV None

Minutes on Plan:

 

I have texting
I would like texting

I have a data plan
I would like a data plan

Months left on current contract:

Number of phones on plan:

I last upgraded my phone(s) approximately:

Months and Years

 

I like my handset
I am interested in updating my handset
I am interested in service without a contract or credit check.

I am interested in a wireless card for my laptop

6. Television Service

Current Provider:

My monthly bill is approximately:

$

Number of receivers:

I am interested in HD Channels:

Yes No

Months left on contract:

I currently have:

HDTV
DVR

7. Computer Support

Current Provider:

My amount to repair a service is approximately:

$

How many computers are in your home?

8. Energy Service

Current Provider:

Type of Service:

Natural Gas Electricity Both

My monthly energy bill is approximately:

$

I am interested in the following:

Residential Electricity Residential Natural Gas Both

9. Mobile Application

Do you make long distance or international calls on your mobile phone?

Yes No

Are you interested in saving money on your mobile phone bill?

Yes No

7. Energy Service

Current Provider:

My monthly energy bill is approximately:

$

Type of Service:

Natural Gas  Electricity  Both 

I am interested in the following: (check all that apply)

Residential Electricity (Ontario Only)
Residential Natural Gas (Ontario, British Columbia and Manitoba)
Business Electricity (Ontario Only)
Business Natural Gas (Ontario, Quebec, British Columbia and Manitoba)
I would like to learn more about living greener

8. Mobile Application

Do you make long distance or international calls on your mobile phone?

Yes No

Are you interested in saving money on your mobile phone bill?

Yes No

Totals

Total Monthly Bill Amount:

$

Total Yearly Bill Amount:

$
Company name:
Address

City:

State:    Zip Code:

Phone Services for Business

Are you a business owner?

Yes No

Are you interested in saving money on your business phone services?

Yes No

How many employees are in your business?

Less than 3
3-50
More than 50

Which of the following features are important to you?

Receiving calls at any location
Traditional features, including Call Transfer
Voice Mail Notification by Email
State-of-the-Art Equipment

Current phone service provider:

My monthly phone bill is approximately:

$

Months left on current contract:

Primary phone number:

Satellite TV for Business

Are you a business owner?

Yes No

Are you interested in saving money on your business TV service?

Yes No

How many stories does your building have?

Is your building a multi-dwelling unit?

Yes No

What type of business establishment do you own? (i.e. restaurant, bank, medical office, etc.)

Who will be watching TV in your establishment?

Employees
Customers

Are you interested in Sports Programming?

Yes No

Are you interested in International Programming?

Yes No

Do you want to reduce your customers perceived wait time and enhance their overall experience?

Yes No

Current TV provider:

My monthly TV bill is approximately:

$

Months left on current contract:

Number of receivers:

Computer Support for Business

Are you a business owner?

Yes No

How often do you use a computer for work?

Daily Weekly Once a Month

Do you have an IT person on staff?

Yes No

When you do need support, are you able to get immediate service?

Yes No

Do you perform a regular backup of all your information?

Yes No

My monthly bill is approximately:

$

Energy Services for Business

Current Provider:

Type of Service:

Natural Gas Electricity Both

My monthly energy bill is approximately:

$

I am interested in the following:

Business Electricity Business Natural Gas Both
   
I am the decision maker of my company and able to make changes to the services used.

Totals

Total Monthly Bill Amount:

$

Total Yearly Bill Amount:

$