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  Application Form

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 : )


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

Unit Price
  Sub Total

Additional Payment Information:

Billing Cycle: From   To        Spec:



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