VZW Third Party Authorization Form

1
ProBiz360 Agent Email* This field is required.
example@example.com
2
Business Name (as registered with VZW)* This field is required.
3
Business Street Address* This field is required.
4
Business City* This field is required.
5
Business State* This field is required.
6
Business ZIP* This field is required.
7
ZIP* This field is required.
8
VZW Registered Email of Authorized Point of Contact (POC)* This field is required.
example@example.com
9
Verizon Profile ID

Obtain this information from your ProBiz 360 Representative. This is also known as your ECPD ID.
10
Profile Number #1* This field is required.
11
Profile Number #2Skip this section if you only were provided one Profile number for your VZW Rep.
12
Profile Number #3Skip this section if you only were provided one Profile number for your VZW Rep.
13
Profile Number #4Skip this section if you only were provided one Profile number for your VZW Rep.
14
Signature* This field is required.
Clear
15
Printed Name of Authorized Signer (on VZW Account)* This field is required.
16
Title (Administrator is typically best)* This field is required.
17
Date* This field is required.
Date
Month
Day
Year
Should be Empty:

Verizon Profile ID