CDM TV- Activation – Clear Digital Media

Please complete all the fields to complete your CDM TV network activation:

Clinic Name*
Clinic Main Phone #*
Clinic Main Address*
Street Address Address Line 2 City State ZIP Code
Website*
Contact Name*
First Last
Contact Direct Phone #*
Contact Email*
Subscription Type*
- Monthly ($75/mo discounted price)
- Annual ($810/yr- addtnl 10% discount)
Number of Subscriptions (1 per store rqrd)*
Credit Card #*
Name on Card*
Expiration Date*
MM/YY
Billing Zip Code*
Sec Code*
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