EMBARQ™ Customer Referral Form - Residential

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Thank you for your interest in submitting an EMBARQ™ Customer Referral. We are pleased that you are happy with your service and want to refer someone who will enjoy the same benefits.

Prior to referring EMBARQ™ service, check availability by simply clicking on Availability. Please enter the address of the person you wish to refer and hit enter. If your referral is capable of receiving EMBARQ Local Service in their home, you will be directed to the New Services page. If they are eligible, you can submit a referral for EMBARQ services.

Prior to referring EMBARQ™ High-Speed Internet, check availability by simply clicking on Availability & Pricing. Please enter the area code and phone number of the person you wish to refer and hit enter. If your referral is capable of receiving EMBARQ High-Speed Internet in their home, the following message will appear, “Great News! EMBARQ High-Speed Internet service is available in your area.” If they are eligible, you can submit a referral for EMBARQ High-Speed Internet.

Please indicate whether this is a New Customer referral or an Existing Customer referral, check the product box(s) you would like to refer, and complete all of the form information below. Submitter must currently subscribe to the EMBARQ® product which they are referring and may submit multiple referrals.

New Customer Referrals

If the person you refer activates new service and signs-up for the selected product within 60 days of your referral, you will be notified and a $50 credit will be issued to your account. To receive this credit, the person you refer must sign-up and have an active account. You may receive one $50 credit per referred person.

Existing Customer Referrals

If the person you refer signs-up for the selected product within 60 days of your referral, you will be notified and a $25 credit will be issued to your account. To receive this credit, the person you refer must sign-up and have an active account. For multiple selected products, you are eligible for a $25 credit per product.

We appreciate your interest and encourage you to refer as many people as you want. The more you refer, the more credits you can earn!

Starred ( ) items are required.

Referral Type:

New Customer Referral
Existing Customer Referral

Referral Products:

EMBARQ™ High-Speed Internet
EMBARQ™ RescueIT - Computer Support
DISH Network® Satellite TV from EMBARQ
Unlimited Long Distance with qualified Home Phone Service package

Your name:

First Name
Last Name
Address
City			State
Zip

Your EMBARQ Home Telephone Number:
( ) -

Your e-Mail Address:

Your referral's name:

First Name
Last Name
Address
City			State
Zip

Did you check your referral's address, phone number and zip code for availability and coverage for local service or High-Speed Internet?


Referral's Home Telephone Number:		( ) -

Referral's e-Mail Address:

EMBARQ™ Customer Referral Program (“Program”)
Terms & Conditions
Services may not be available everywhere. EMBARQ may add, modify or delete any terms of the Program at its discretion without notice. Additional restrictions may apply. The submitter (“Submitter”) is defined as the person who submits the name(s) and information of the referral (“Referral”). The Submitter must be an existing EMBARQ® residential customer in good credit standing who currently subscribes to EMBARQ® High-Speed Internet and/or DISH Network® Satellite TV and/or EMBARQ® Rescue IT^SM - Computer Support and/or Home Phone Unlimited Long Distance bundled with either Premium Home Phone, Basic Home Phone II or Basic Home Phone III service (“Current Services”). The Submitter must submit the official, fully completed online EMBARQ® Customer Referral form (“Form”) at embarq.com/referral to be eligible – no written or verbal referrals accepted. Submitter must currently subscribe to the EMBARQ® product which they are referring and may submit multiple referrals. The Referral is the individual who is being referred – either a new customer to EMBARQ (“New Referral”) or an existing customer of EMBARQ (“Customer Referral”) adding a new EMBARQ® service to their existing account. EMBARQ may reject any Referral at its sole discretion. In order for the Submitter to be eligible for an invoice credit (“Credit”), the Referral must sign up for a qualifying service (“Qualifying Service”). Qualifying Services include: Residential EMBARQ® High-Speed Internet; EMBARQ® Rescue IT^SM - Computer Support; DISH Network® Satellite TV from EMBARQ; or Home Phone Unlimited Long Distance service with new Standard Home Phone, Premium Home Phone, Basic Home Phone II or Basic Home Phone III. The Referral must activate the Qualifying Service within 60 days of the submitted Form (according to date and time of online entry). EMBARQ may change any of the Qualifying Services at any time without notice. Submitter will receive one $25 Credit per Qualifying Service for Customer Referral and one $50 Credit for New Customer with qualifying services. The Credit will be applied to the Submitter’s applicable invoice approximately 60 days after the Referral’s Qualifying Service has been activated. Referral’s Qualifying Service must be activated within the 60 days of the submitted Form. Only one $25 Customer Referral Credit or one $50 New Referral Credit will be applied at a time to a Submitter’s invoice; additional Credits will be applied to subsequent Submitter’s invoices. The first Submitter to submit a Referral (according to date and time of online entry) will be eligible to receive credit if multiple entries are received on same Referral. After 60 days, the entry is no longer valid but the Submitter may resubmit Referral. Accumulated Credits do not have cash value and are not redeemable for cash. All Credits will be forfeited if the Submitter cancels their Current Service or becomes ineligible to participate in the Program.