Name

Account Number**

SSN / EIN*

Account Email Address

VZW Username**

Account Password**

Current Rate Plan**

Special Features

Accessories Needed

Decision Maker Name+

Decision Maker Email+

----- ENTER CURRENT PHONE INFO ----

Trade In Devices (please specify any/all devices you are considering trading in: no physical damage, no water damage, device powers on)

Line 1 Phone Number

Line 2 Phone Number

Line 1 Insurance (accept/decline)

Line 2 Insurance (accept/decline)

Line 1 Device***

Line 2 Device***

Line 3 Phone Number

Line 4 Phone Number

Line 3 Insurance (accept/decline)

Line 4 Insurance (accept/decline)

Line 3 Device***

Line 4 Device***

Line 5 Phone Number

Line 6 Phone Number

Line 5 Insurance (accept/decline)

Line 6 Insurance (accept/decline)

Line 5 Device***

Line 6 Device***

Enter Additional Phone Numbers / Info Here (if needed)

---- ENTER SHIPPING & BILLING INFO ----

Shipping Choice: CHOOSE ONE: Standard (FREE) | Overnight ($12.99) | Priority Overnight ($14.99) | Overnight Saturday Delivery ($19.99)

Shipping Address

Shipping Address 2

Shipping City, State, Zip

Billing Address

Billing Address 2

Billing City, State, Zip

Name on Credit Card

Credit Card Number

Card Expiration Date

Card Security Code (CVV)