Qwest® Spirit of Service® For questions on order referrals submitted via this webform call 888-273-9220 or contact your Qwest representative.
Welcome to the Indirect Retail Referral Webform. *Required fields
 
Name of SALES PERSON Submitting Order *
Contact Number of SALES PERSON Submitting Order *
Email Address of SALES PERSON Submitting Order *
SALES PERSON's Sales Code *
Has a Satellite TV order already been placed with Satellite vendor?       Yes       No      
Who is your Qwest Sales Manager?
ATTENTION:
All information from this point forward should be the customer's. Inputting sales person or store information in place of customer's is a violation of Qwest's policies and procedures.
Customer Name *    
Customer Billing Address *    
Customer Billing Address 2 (Apt #, Suite, etc.)      
Customer Billing City *    
Customer Billing State *       Customer Billing Zip *
Is this a Multi Dwelling Unit (MDU)? Yes       No      
(Apt, Condo, Townhouse, ETC…)    
 

IMPORTANT NOTE: Any customer information not directly input into Qwest's Winback Webform that may be written on paper or contained in other electronic devices must be securely destroyed, for example by shredding or erasing the information as soon as the information is input into Qwest's system.

If service address is different from the billing address above, please include that below.
Best Time to Call *    
this is not a guaranteed time to call, please add any special instructions in the notes section.
Best number to reach customer *   
Alternate Number to Reach Customer    
Existing Provider *   
Service Address (if different than above)
Service Address    
Service Address Line 2    
Service Apartment/Unit    
Service Building    
Service City    
Service State    
Service Zip/Postal    
 
   Winback (was a previous Qwest customer)
   Winover (Has never been a Qwest customer and is porting their current number to Qwest with this order)
   Porting number from a different carrier?        Provide the number to port
PRODUCT(S) INTERESTED:
Voice Products:
    Basic Line
    Qwest Home Phone Plus (includes 5 cent LD)
    Qwest Home Phone Unlimited (includes unlimited LD)
    Qwest Home Phone (no LD)
HSI
    1.5
    3 / 5 / 7
    3 / 5 / 7 + 5M upload
    12 M
    12 M + 5M upload
    20 M
    20 M + 5M upload
    40 M
    40 M + 5M upload
Modem options will be discussed with customer during callback.
 
Additional Questions, Comments or Requests
REMINDER: You are about to submit a referral for Qwest products. This order will not be complete until customer is contacted by a Qwest representative and order is entered directly into Qwest Systems.
 
IMPORTANT NOTE: Any customer information not directly input into Qwest's Webform that may be written on paper or contained in other electronic devices must be securely destroyed, for example by shredding or erasing the information as soon as the information is input into Qwest's system.

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