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<br /> <br />? LrA.tE ?UBM3?_- <br />--- _- <br />...----•- <br />? rJr1510H ' <br />' ` S?BMt??ED BY: JoSM BAFtD <br />i.AARKET: ChDO'e oF1e: <br />MOBILE CONTACT#. ; 4404123-1380 <br />NETACE DEALER CODE WB88.. ,.?`_. , ._._?.?. . <br />CEISTOJ4tER 1NfORMAT70M <br />CQRP: Choose Qne tND Chrsnsa One <br />{ ACCOUNT AME:___ I Cty of NeRh Otmtiieci <br />? ATTEN310N: Mary Sslntort? <br />' ADDRE5S 1: 5200 Da+rer Cer?r Rd. <br />AQaRESS 2: <br />GITY, S7ATE, ?Ip: f?lorth ?Imsted, C?H N07Q <br />' C?NTAC7 HOMEM. _?__ <br />?CONTA-Gt W(?f2K#: 4?Ck?1!l-+/16i0 _ <br />D.4T? E pf gIRTH: <br />pRIVERS l1C?N5?: <br />i EMPLOYER NAME' <br />FED? j IDl SSN: <br />. YRS !N BU5114E5S: <br /> <br />IM/'1„vYtrefeSS <br />DIRECT FULFILLMENT ORDER FORM <br />12K1NetAce <br />SHIPP?NG tNFORMAFlaN <br />SH4f' ZQ Nf?M?: i 5etn? __ <br />ATTENTION: <br />AddRESS: <br />ADpRESS 2: <br />ClTY, STATE: <br />21P CbDE: <br />SHiP Tt? CONTACT #'. <br />RUSH 4RDEa:.,.._ No <br />_...._..._._. .... ._.......__._...__?._........___... _._..? <br />C13?STQMEFt E MAlL ADDRESS <br />?______?..y'?4?n?,'•o+mstea,co?m _._.,. ...__..-.... ..._.____-? <br />RCCOUNT(NFiyaMA'ftON <br />?..- _?._._...... ._.__........._.._.,._.CE.,_.._ <br />rt d+ftere?at than above) r•• <br />SERVICE BlLLING ADORESS: (' ._.---•-----...... 91LLING PREFEREN: Choose one <br />5iLl TO i+IAME: ] Some....._???.._.. MASTER ACGOUNI'#: <br />AFTENIION <br />- <br />ADDI. <br />ADDRESS 2. <br />CI 7.._...___.--------- <br />EXtSTING MTN: <br />T?( EXEMPT ICJ* <br />TIE CODE <br />OROER DESK t1S€ ONLY` <br />ORDER DESK REP: <br />APPIIGATfON <br />NE1'ACE ORDER k <br />TRACKING <br />C3RDER STATU5: (Comple?sd, Pending, Ungale tQ ' <br />? <br />Proaese i <br />? COMPLETED -- <br />PENQtNG qRDER DUE TCJ (check ane) <br />atl7 oF 5`tocK <br />IN CC7lLECTIQNS <br />D?POSI1' ?tEnUIRED <br />? PRtCE PI.AN FRbZEN <br />UNABLE TO PR4CESS DUE T0: ahec? one <br />FINANCE APPROVAL REQlJ1RED <br />{NACCURAT'FJiNCOMPLETE <br />?omments: <br />sERVrcS c?tscounrTs <br />MONTHLY ACCESS BU51NES5 QI5C' °1b <br />MONTNLY ACCESS Ct7RW EMP DISC: 95 <br />Ab[7 E-Z PAY: Chayse One <br />EXP DATE: CG# <br />IBAS ACCOUtdT: ? YES N NQ <br />iBAS MJR AGCNT COC1E: <br />__--... -----. _-. . <br />...?. W. .- <br />k Z? 1P COIJE.._..._.I..._. _, ' . . <br />_._._?... -S? 7h?s?rvifi bc for?a 2 year Renev?al f?r ALL Li'nee of Service on Existi?g ?A?ct. ? 5i 1658614. ?All plana & feature?s tn remain the sarra.e (34? L+nes ot 8ervice ; <br />COMMENT - • ' <br />I are etiQibJe Mr new equipment at na cost {4 L'm?s at Sarv?ca arr?e not e{igtbNe br new e4unp+?nt 1'at1. ..----..._..._. <br />. ... ....... .-•------- ......-----... ..........__.._....... ...._.._----- ._.. . ...__._._...._.. . . Hnss <br />._ _ . . . --- .. . ? . ... . __... . bn behelf ot Cuttomev, f ekd ta subocritse to i0+e scWiNonal <br />custorrwr and Vsfton UYInltM ere pe40,9 ta f Bervia AOreemrrtt puewant W vfikh Verizot+ 1MIm" pmvidet w1rNMs mvia ta Cm!*xw• ksl?r?s reM?Hrr? ta Etrfy 7ermdnatlon Fsea. 1 am <br />ot service srtd Durchas? rdditionat w3ro? phonas, s?t d?b?1 at??ov+, Pursugnt to ?t ? an r?d re? at ?fl ?edlt i?nfamafost. lu derstand? th?t? revOrddr ia subjed to revirw and toosRtanat hy V?rizo? <br />authoficed m am.u? this 8n4er Form on be?hsEf MCue6omer, ind 1authorixe tM in+ratl?at? <br />WireNss. <br />e-` Date: l <br />Customer Slqnature: Saiea Representa'ave: <br />L??