1. What is your full legal name?

The name you use on official documents, like your Social Security Card or State ID. Not a nickname.

.               

2. Your Phone Number?

3. Your Date Of Birth?

4. Your Email

5. What is your home address? (The address where you will get service. Do not use a P.O. Box.)

               

                           

9. Upload document (Proof of Identity).

10. Address Update
I agree to notify my service provider within 30 days if my address changes.

11. Reinstatement Consent
I give permission to my service provider to reinstate services, if needed, using the same number and service package.

12. Single Service Acknowledgment
I understand this is a one-time prepaid service and no additional services will be provided without further payment.

13. Data Use Consent
I consent to my information being collected and used solely for processing this invoice and service.

14. Accuracy of Information
I confirm that all information I have provided is accurate to the best of my knowledge.

Leave this empty:

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Signature Certificate
Document name: IJ Wireless Consent Form
lock iconUnique Document ID: 0431a5f6cf0d1e3943c155df9d6e55d2cefb1900
Timestamp Audit
March 7, 2024 12:46 pm -05IJ Wireless Consent Form Uploaded by IJ Wireless - support@ijwireless.us IP 2400:adcc:2105:5e00:311d:5752:fca2:9b4a