PIN Code:___________     _____________________    ________________________

Name:_______________________________________________________________

Home Address:________________________________________________________

City:_______________________________  State:_______   Zip:_________________

Mailing Address if different_______________________________________________

Home Phone #: ____________________Alternate Phone #: _____________________

Social Security #:__________________________Date of Birth___________________

Driver's License # _________________State:__________Expiration_Date:_________

Do your authorize Verizon Wireless to perform
a credit check?Yes_______No___________

Signature:__________________________________________Date:______________

Deposit Required?_Yes_______No________   Deposit Amount___________________

____________________________________________________________________

Phone Selection: __________________________ Phone Plan:___________________