📱 Customer Intake Form — Total Wireless

📅 Let’s Get You Connected — Customer Information Form 👋

Quick and easy appointments for prepaid plans, repairs, upgrades, and more
Full Name*

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
We’ll call or text if needed.
Reason for Visit*
Previous Carrier
Account Number
Transfer Port Pin Number
Number of Lines
IMEI if keeping same phone (optional, with *#06# help)
Comments?
✅ Confirmation*
Should be Empty:

📅 Let’s Get You Connected — Customer Information Form 👋