Language
English (US)
Español
📅 Let’s Get You Connected — Customer Information Form 👋
Quick and easy appointments for prepaid plans, repairs, upgrades, and more
Full Name
*
First Name
Last Name
Email
*
example@example.com
Last 4 digits of SSN
For Lifeline Only
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
We’ll call or text if needed.
Format: (000) 000-0000.
Reason for Visit
*
Please Select
🔄 Port-In/Transfer/Switch
🅕 Activation (new line/lifeline)
🌐 Home Internet
💻 Tablet / Data Plans
❓ Other
Previous Carrier
*
Account Number
*
Number transfer PIN
*
Number of Lines
*
Please Select
1
2
3
4
5
Phone 1 IMEI
dial *#06#
Phone 2 IMEI
dial *#06#
Phone 3 IMEI
dial *#06#
Phone 4 IMEI
dial *#06#
Phone 5 IMEI
dial *#06#
Photo ID
*
Browse Files
Drag and drop files here
Choose a file
Photo ID
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Proof of Government Program/Benefits for LIfeline only
Cancel
of
Comments?
Submit
Should be Empty: