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Company Name

Address

Contact Name

City

Contact Title

State

Telephone

ZIP Code

Fax Telephone


Email Address

Do you own or lease the building?

Own Lease

Approximate square footage of building.

  Square feet

Do you currently have cable or satellite service in the building?

Yes No

If yes, who is the provider?

If yes, what do you pay per month?

  $/mo

If yes, are you currently under a contract?

Yes No

If yes, when does the contract expire?

Healthcare Facilities - How many beds does your facility have?

How many rooms does the premises have?

How many televisions are currently on the premises?

Do you plan to add additional televisions?

Yes No

How many independent television receivers require separate signals?

Is the building single story or multi story?

Single Multi

What is the roof type?

Flat Pitched

What type of business is your establishment?

What channels/programs MUST be available?
(Maximum 5 choices)






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