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User Information
  DIRECTV DSL Value Package
 $49.99 per month
  Connect and Protect™ Upgrade $9.99 per month
  First Name:*
  Middle Name:*
  Last Name:*
  Enter DSL Number:    
  Enter Contact Phone Number:    
  Email Address: **  
   Do You Currently Have DSL? yes no
Address Information
  Street Address:*  
  Apt/Suite: *  
  City:*  
  State:*  
  Zip Code:*  
  Country:*        USA
User's Telocity Account Password
  User Name:*  
  Password:*  
  Password verify:*  
  Reminder Phrase:*  
Shipping Address
  Same as Address above:*   uncheck if different
  Street Address:  
  Apt/Suite:  
  City:  
  State:  
  Zip Code:  
  Country:  
Billing Address
  Same as Address above:*   uncheck if different
  Street Address:  
  Apt/Suite:  
  City:  
  State:  
  Zip Code:  
  Country:  
Credit Card Information
  Card Type:*
  Card Number:*
  Expires:* / mm/yy
  Promo. Code/Affiliate ID:
* If identified by a customer
** Not Required, but preferred