2004-068 Resolution - Laserfiche WebLink

Home Browse Search

.? : ?. ?, • I iLmes r, u ?-t _ I U New - CJ New w/CPE -ransfer of Service J Port In / New Account ?Q? ? Upgrade ?newal ,.;ailing Plan w/Promo ? Port In % Existing Ac.ount ? Add-on ? Port In / Phone # Chanqe - --- -_ - _ _ ' rder # Sales Rep N me / ID do ff ?? AgenUDealer/Su Dealer ID Store / Rep Phone Number ? ?-3? ? ?'=? !?/G • j?'.t?? ? L? /I Group IQ Tie Gode iBAS 1VIAC Code ' BGSA MEA New Wireless #(MDA) TExisting Wireless #(MUA) ? ) ?( ) • •• • Party Financially Responsible for Account - Name (Please Print) ? Corporation ? Proprietorship ? Government U PartnershiG) E-mail Address (Note: By providing your e•mail address you consent to Non-Profit Bill to Company Name/Responsible Party (Please Print) ? Bill To MTN + receive Verizon Wireless promotional opportunities.) tnitiais Home Address' Contact Name (Authorized Business Contact) ?4^/ 4.,U5dA, L- City State ZIP Code Ship To Address` / Shipping Char ge $ (if applic a ble) s T / ? ??' ,? -?U' ??vi ? 7?, /'?.''., Mailing Address (if different) --- City State ZIP Code 0-iv City State ZIP Code Business Phone Years in Business c?) -71r , Lfij-v Federal Tax ID # - ----- Home Phone WorklAlternate Phone Tax Exempt Certification # D&B Number ( ) ( ) _ .,?p _ ??? ? "?pL_. ..- Social Securiiy # Date of Birth Bank Name Bank ContacUNumber Primary ID # - State - Exp. Date ------ Commercial Account # Years at Bank _ Secondary ID# Exp. Date Company Headquarter's Address The Sales Representative acknowledges that he/she has verified the customer's ID. Sales Rep Initiais City State [21P Code Employer / Employer Telephone # - - -- --- *Place of Primary Use - Yes No The home or business address +nd'+cated above is for the person using the phone and is the person's residential street or primary business street address. PERSON • . above) User Name (Please Print) ? o Li/vk, ? Phone c ) Address City State ZIP Code Place of Primary Use - The address above is the user's residential street or primary business street address. _Yes •O• • • • d Service P . .- •• • Por[ In Number OSP account # Password / PIN Billing Address / Name w/OSP (If different from above) Type of Number (i.e., Landline or Wireless) (JSP name lniYials SERVICE a• • •• • • Calling Plan Name & Code Activation Fee Promotion(s): $-,0-' ? Check here for NO PROMOTION Monthly Access3f ? Allowance Minutes ? I understand that t am receiving the first month(s) of at no charge. Included: ??? W, After this period, I will be charged $ per month. I understand that I can cancel this feature at anytime by calling *611 on my wireless phone. $ Month Month lnitials ? Check here if NOT APPLICABLE ENHANCED . . . .- .. - $ ? Enhanced V oice Mail ? Select ? Decline Total EquiPment Covera es'" $ V ice Mail _ $ Detaited Bi{fing ?'? _ $ O Select G7 Deciine Extended Warranty -- $ II Waiting_ $ ? Mobile to Mobile _ $ ? Select ? Decline Wireless Phone Proteetion* ? $ il Forwarding_^_ ____ $ ? TXT Messa in $ ? Other $ a Callin $ ? Mobile Web $ ? Other $ Caller ID 1 select or decline Wireless Phone Protectioni and understand if I decline, I am responsible for replacement equipment at a non-discounted price. Initials " Provided by third-party insurec • •• • Price Non-Discounted Price Electronic Serial Number (ESN) Model Lock Code ? MIN (Check if ported) $ $ - --- - -_ -- SKU#/Prod ID Equipment ? $ Other _- $ SKU#/Prod ID Accessory #1 $ - Trade-in/Rebate/Discount $ ? - - SKU#lProd ID ? Accessory #2 $ - - Sub-total - - $ SKU#/Prod 1D Accessory #3 $ Sales Tax $ Paid By: ? ChecWMoney Order/ # ? C dit C d P O Programming Fee $ re ar . . ? Cash ? Other -- Security Deposit Amount $ Total Due $ Credit Card # Exp. Date Name as it appears on Credit Card Credit Card/Check Approval # -• • ? One (1) wo (2) ? Other f am personally responsible for paymem of alt charges associated with this account (OR) I am Year ear ' signing on behalf of the Company listed above as Responsible Party and I am duly authorized to ' financialty commit the company. If I am not authorized, I will pay the charges if the Company named Initiais Initials denies responsibility. BY SIGNING THIS FORM YOU'RE AGREEING TO THE ATTACHED CUSTOMER AGREEMENT. PLEASE READ THE AGREEMENT AND YQUR CALLING PLAN. THE CUSTOMER AGREEMENT SETS YOUR AND OUR RIGHTS CONCERNING PAYMENTS, CRED{TS, CHARGES, STARTfNG AND ENDING SERVICE, LOCAL NUMBER PORTABlLITY, EARLY TERMINATION FEE OF $175, LlMITATIONS OF LIABILITY, SETTLEMENT OF DfSPUTES BY iVEU i RAL ARBITRATION AND OTHER MEANS INSTEAD OF JURY TRIALS, AND OTNER IMPORTANT 70PICS. BY SIGNiNG TH4S FORM YOU ARE AllTHORiZING US TO INVtST1GATE YOUR CREDIT HiSTORY AND SHARE CREDIT IlUFORMATION ABOUT YOU WITH GREDIT REPORTiNG AGENCIES. WE CAN CONTACT ANY OF TNE REFEfiENCES YOU LISTED. WE GAN ALSI? CONTACT YOUR COMPANY !F YOU ARE SIGNiNG ON BEHALF 0F 1T. BY SIGNING fT YOU ARE REPRESENTlNC TNRT ALL TFiE iNFORNiAjfON YOU PRDVidED 1S ACCURA7E. WE NRE RELYING ON THAT kh1FORMATiON. A C(lPY OR FAX OF THIS FORM 1NITPI Vl1UR SIGNATURE iS THE SAME AS AN ORlGINAt. Customer Signature Print Name Date _ Page of _ fORM VZVY CA 10/03 0,- f... `JER{ZON CC3{'Y