©ACN Opportunity, LLC 2012 HSSEnergy_W_CC_041112

Connecting you, your family, your friends... your LIFE!

Total Monthly Bill Amount $ _________________Total Yearly Bill Amount $ _________________

PERSON WHO INVITED ME:COMMENTS:

Friend or Family Member

National Provider

Remote Service

Self-help

Name ____________________________________________________

Address ___________________________________________________

City _________________________State_____Zip Code ____________

Email____________________________Phone # __________________

Rent Own

Current Provider __________________________________________________________________

Primary Phone Number ____________________________________________________________

My monthly bill is approximately $ __________________________________________________• Bundled with: Internet TV Both• Total Bill $_____________

International Calls: Yes NoLong Distance: Yes NoI am interested in Unlimited Calling: Yes No

Local/Long Distance Service1

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________• Type of Service: Cable Dial-Up DSL Wireless Aircard (Provider_______)• Bundled with: TV Phone Both

High Speed Internet Service2

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

Digital Phone Service3

Current Provider __________________________________________________________________

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

My monthly bill is approximately $_______ Minutes on plan______

Months left on current contract ______ Number of phones on plan ______Do you currently have a texting plan? Yes No Data Plan included? Yes No

I last upgraded my phone(s) approximately: ____ Months ____ Years

Wireless Service4

I like my handsetI am interested in updating my handset

I am interested in service without a contract or credit checkI am interested in a wireless card for my laptop

Do you make long distance or international calls on your mobile phone? Yes NoAre you interested in saving money on your mobile phone bill? Yes No

Mobile Application5

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________• Bundled with: Internet Phone Both

Number of receivers______ Months left on contract ______I currently have HDTV DVR

TV Service6

Home Security & Automation Service7

Current Provider __________________________________________________________________Do you perform a regular backup of all your files? Yes NoHave you ever had a computer virus? Yes No

Amount spent on average computer repair incident $________

Please select the type of computer support services you’ve used in the past

Computer Support8

Current Provider __________________________________________________________________Type of Service Natural Gas Electricity Both

My monthly bill is approximately $____________I am interested in the following: (check all that apply) Residential Electricity Residential Natural GasBusiness Electricity Business Natural Gas

Energy9

Current Provider __________________________________________________________________

My monthly bill is approximately $ __________________________________________________

I am currently a: Homeowner Renter

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