Home Services Survey

Reinhardt Leadership Team

Home Services Survey

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Referred By *

Phone Number *

Email *

Home *

Rent Own

TELEPHONE

Do you have a home phone? *

Yes No

Do you have more than one line? *

Yes No

Current Provider? *

Bundled with: *

TV Internet Both

Do you have unlimited calling? *

Yes No

Do you make long distance calls? *

Yes No

International calls? *

Yes No

How much is the monthly bill? *

WIRELESS

Current Provider? *

When does your contract(s) expire? *

Last phone upgrade? *

How many phones do you have? *

How many minutes on your plan? *

What kind of phones do you have? *

Does your plan include unlimited data/texts? *

Yes No

Access Internet on your phone mostly at home? *

Yes No

How much is the monthly bill? *

INTERNET

Current Provider? *

Fast or Slow (or if speed known)? *

Bundled with: *

TV Phone Both

How much is the monthly bill? *

HOME SECURITY

Do you have a home security system? *

Yes No

Current Provider? *

Months left on contract? *

How much is the monthly bill? *

TECHNICAL SUPPORT

Current Provider? *

Do you perform a regular backup of all your files? *

Yes No

Have you ever had a computer virus? *

Yes No

Amount spent on average computer repair incident? *

TELEVISION

Do you currently pay for TV? *

Yes No

Current Provider? *

Number of Receivers (TVs connected) *

Do you have: *

HDTV DVR Both

How much is the monthly bill? *

ENERGY

Current Electric Provider? *

Current Gas Provider? *

How much is your average Electric bill? *

Your Gas bill? *

Total

Total Monthly Amount *

Total Yearly Amount *

Submit

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