Wireless Activation Request Form

Complete the form below after completing your Wireless Service purchase.

Section A: Customer Information (must match with the information on your order)

First Name:

Last Name:


Order Number:

Section B: Complete the following to activate with a New Mobile Number. Skip to Section D, agree to the Terms, and click the "Submit" button.

Area Code:

Zip Code:

Section C: Complete the following for Port-In Activations. Transferring your mobile number may take up to 3 business days to complete depending upon the previous service provider's system.

Old Service Provider:

Mobile number to transfer:
Check here if the mobile number is under contract.

Account Holder's First Name:

Account Holder's Last Name:

Account Number (No special characters or spaces allowed):

Account Password/PIN:

Account Address:



Zip Code:

Section D: Terms and Conditions

My Wireless Service purchase will be activated using the information that I have provided above. I agree that there are no returns or exchanges on SIM cards or Wireless Refills.

Thank you for your purchase!