Simple Touch Wireless Service Application

Reference #:                Date :
Deposit : $                Sales Rep:
Line Available :1 2 3 4


1. General Information
Have you had T-Mobile, Verizon or Cingular account Previously?    Yes    No
(Name of Company : )


Name:

Social Sercurity # or Tax ID:

Address (Home): City: State:  Zip:

Billing Address:

Home Phone: Other Phone:  

Date of Birth:  

Driver's License: Exp. Date: State:

Preferred Password:   Desired Area Code:


2. Service Plan

A. Plan Amount:
    
B. Plan Option:  Long Distance   Off-Peak Option   Wireless Web Service
   
C. Additional Minute:
   
D. Additional Option;


3. Equipment  &  Accessories

Qty	Model	ESN	Unit Price	Total
			Sub Total
			Tax
			Total

Additional Payment Information:

Billing Cycle: From   To        Spec: