Dr Wireless Personal Account Worksheet

For Porting an Existing Number Only

Questions?   Call us!   (310) 400-4900



First Name:
   
Cell Phone:
   
Last Name:
   
Office Phone:
   
eMail Address:
   
Fax Number:
   
 
   
 
   
-------------- Billing Address ----------------------------------------- Shipping Address -----------
 
   
 
   
Name:
   
Name:
   
Street:
   
Street:
   
Apt/Suite:
   
Apt/Suite:
   
City:
   
City:
   
Zip Code:
   
Zip Code:
   
 
   
 
   
------------------------------------------ Service Details ------------------------------------------
 
   
 
   
Account Password:
   
Preferred Phone Make/Model:
   
Phone Number to Port:
   
Preferred Carrier:
   
Current Account Number:
   
Current Carrier:
   
Peak Usage (Minutes):
   
Monthly Budget:
   
Data Plan:
   
PIN or Challenge Answer:
   
Contract Length:
   
Device Insurance:
   
 
   
 
   
Dr Wireless Options
   
 
   
WIN Plan:
     [ what's this? ]
BlackBerry Support:
     [ more info ]
 
   
 
   

Your discretion is our obsession! For security purposes we would
prefer to take sensitive information (Social Security, Fed Tax ID Numbers,
Credit Card Numbers, Drivers License Numbers etc) over the phone. Once your
application is received, we will contact you for this information.