Name:

Address:
              
              
              

Home Tel. No.

Mobile Tel. No.

Facsimile No.

E-Mail Address:

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Were You a DirecTV Dealer:
Yes      No

From When to When: (mm/dd/yyyy to mm/dd/yyyy)

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What Is or Was the Name of Your Company:

What Is or Was the Address of Your Company:
                                                                               (Street Address, City, State, Zip Code)

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Did You Sign a Residential Dealer Agreement:
Yes      No

When: (mm/dd/yyyy)

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Did You Sign a Sales Agency Agreement:
Yes      No

When: (mm/dd/yyyy)

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Did You Have a Sales Management Agent (SMA):
Yes      No

Name of SMA:

Date of Agreement, if any, with SMA: (mm/dd/yyyy)

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Did You Earn and Receive Commissions as a DirecTV Dealer:
Yes      No

Do You Believe That Your Commissions Were Properly Calculated:
Yes      No


Why or Why Not?

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Were You Assessed Charge-Backs By DirecTV:
Yes      No

Were The Charge-Backs Properly Calculated:
Yes      No


How Much in Charge-Backs has DirecTV Assessed Against You:

How Much Do You Believe You Are Owed in Total by DirecTV:



Have You Kept Records of the Amounts You Believe You are Owed by DirecTV:

Excellent Records            Some Records            Little or No Records

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