Please provide the following contact information:

Personal Information

First name
Middle
Last name
Date of Birth
Social Security #
Driver Lic
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
Home Phone
E-mail

Please select a plan from the list below:

Cellular Plan	Solution 200 $29.99 Solution 300 $39.99 Solution 500 $49.99 Solution 1600 USA $169.99

Please select a cellular phone from the list below:

Cellular Phone Type

Motorola V8160 Motorola Timeport P8160 Motorola Startac 8868 Motorola Startac P8610 Qualcomm 860 Nokia 5180 Nokia 6180 Audiovox 3300

Please select any optional services if desired:

Optional Services

Free Voice Mail - Caller ID - Free Long Distance Standard Voicemail (FREE) Caller ID (FREE) Call Waiting (FREE)

Please provide the following ordering information:

	Credit Card information (optional)
Credit card	VISA MasterCard American Express
Cardholder name
Card number
Expiration date

	SHIPPING (If different from above)
Street address
Address (cont.)
City
State/Province
Zip/Postal code

       Comments:      

Do you agree to the terms and conditions as outlined above: I agree No, I DO NOT agree

You must accept the terms and conditions for your order to be proccessed.   Selecting "I agree" is the electronic equivalent to signing your name.