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- / E. Wireless

Service: Verizon

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Pierre Izard

communlcatlons

1310 Westwood Blvd.

Los Angeles, CA 90024
(310) 315-1300 (310) 582-1135 FAX

VERIZON PREPAID NATIONAL PLAN APPLICATION

Date:

Please check all boxes that apply:

New Account

Birthdate: _ _ _ _ __
Email Billing Only: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Home Phone: - - - - - - Business Phone:

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Company Name/OBA:
Home Address:

- - - - - - - - - - - - - - - City: - - - - - - - - - State: - - - - Zip:- - - -

Billing Address:
(If different)
- - - - - - - - - - - - - - City: _ _ _ _ _ _ _ _ State: _ _ _ Zip: _ _ __
Drivers Lie No:

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Un Ii mite d Per Paid National Plan

Monthly Access Fee

Exp Date: _ _ _ __

SSN:

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Mobile# (
Proration $ 4.50 *
+ $135.00

$ 135.00

Days

=$

includes unlimited talk text and data

+ $ 35.00
Processing fee

$ 35.00

411 calls

1.99

Total Amount Due

No international call
No international roaming
Reactivation fee

$25.00

Billing cycle 24th to 23rd of following month

Advance payment of a full month and prorated of the first cycle( $3.30 per day) plus activation fee is required at
the time of activation
Mobile number will be suspended if payment is not received on 23rd of each month for the next cycle.
All extra feature is due at the time of usage.
Credit Card Information:
Card Number:

Visa

Mastercard

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American Express
Exp. Date: _ _ _ __

Sales Agent: _ _ _ _ _ _ _ _ _ _ _ _ Account#: _ _ _ _ __

No. of phones:

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Approved by:

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Referred by: _ _ _ _ _ __
Approval date: _ _ _ _ __