Verizon Wireless Credit Application by ps94506

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									                                                                                                               Verizon Wireless
 312 Sunnyfield Drive, Suite 200
                                                                                                              Credit Application
                                                                                                                     Please E-Mail or Fax completed Forms to:
 Glenshaw, PA 15116-1936
 Phone: 412-213-2477 Fax: 412-492-9386                     Fill out, Save, Print and E-Mail this form using Acrobat Reader 7 or 8!                sales@proxicast.com
                                                                            Save Form        Print Form       E-Mail Form        Reset Form        FAX: 412-492-9386

 As a convenience, Proxicast can establish a cellular data service plan and account with Verizon Wireless on your behalf. Activation of your
 PC-Card modem will result in a new Verizon Wireless account and mobile telephone number, unless service is being added to an exi sting
 account that Proxicast created on your behalf. Adding or transferring lines to accounts created by other activation agents or Verizon Wireless
 representatives is solely the customer’s responsibility.

 Activation of each device (and its associated mobile telephone number) rep resents a contractual commitment to service with Verizon
 Wireless. Proxicast (and/or its affiliates) serve only as an activation agent for Verizon Wireless; all sales and use of cellular services
 shall be governed by Verizon Wireless’ terms and conditions. Credit authorization, application acceptance, and wireless data service
 costs are determined at the sole discretion of Verizon Wireless. Once Proxicast has performed the account creation and activation, all
 matters involving cellular service are handled directly between the customer and Verizon Wireless. See: http://www.vzw.com for details.

 You will be billed directly by Verizon Wireless for all fees, charges, taxes and other related service plan costs. Your account may be subject
 to a security deposit, activation, and/or early termination fees as determined by Verizon Wireless. You will receive a Wireless Service
 Agreement which describes the specific terms in detail. You may cancel your service, for any reason and without incurring the Early
 Termination Fee, within fifteen (15) days of signing your Wireless Service Agreement, PROVIDED, however, that if you cancel service you will
 remain responsible for any service fees and charges incurred.

 NOTE: You may apply for service as either a Business Entity or as a Personal Account.

 * All fields are required * in the corresponding section in order to submit your application to Verizon Wireless.

 BUSINESS APPLICATION
                             Main Business Location                                                                   Billing Address
 Company: ________________________________________                          __      Contact:         ________________________________________                               __
 Address:       ________________________________________                    __      Address:         ________________________________________                               __
                ________________________________________                    __                       ________________________________________                               __
 Main Phone: _______              ______________ ___________                  _     Phone:           ________________________________________                               __
 Tax ID: ______________                ___     Yrs in Business: _____ _____         Authorized User: __ _______                                                            _

 PERSONAL APPLICATION                                                                                  Verizon Wireless may require a security deposit prior to establishing a
                                                                                                       new service account. If a security deposit is required, Proxicast will
 Name:          ________________________________________                    __                         contact you to obtain permission to bill the security deposit to your
                                                                                                       credit card.
 Address:       ________________________________________                    __
                                                                                                       NOTE: Static IP Service is not available for Personal Accounts.
                ________________________________________                    __

 Phone:        ________________________________________                     __    E-Mail:       ________________________________________                                   ___

 Date of Birth: ___________                   SSN: _________           __         Drivers License #: _ ______                    ___                      State: __ ____

  2                                                                                                                   *Excludes tolls, taxes, surcharges and other fees,
  yr
                              Service Plan                            Base Monthly Access Fee *                       such as E911 and gross receipt charges which
                                                                                                                      vary by market and as of October 1, 2011, add
                                                                    $59.99/Month + $0.05 per MB                       between 6% and 34% to your monthly bill and
          Broadband Access (EV-DO) 5 GB/Month Plan                                                                    are in addition to your monthly access fees and
                                                                          over 5 GB/Month
                                                                                                                      airtime charges. Monthly Federal Universal
                                                                                                                      Service Charge (varies quarterly based on FCC
          Sierra Wireless AirCard 595                                                                                 rate) is 14.4% per line as of Oct 1, 2011.
          Please complete Hardware Sales Agreement               Contact Proxicast for current promotional pricing    Monthly Regulatory & Administrative Charges
                                                                                                                      (subject to change) are 99¢ per line. The
          Novatel Wireless USB760                                                                                     Federal Universal Service, Regulatory &
                                                                                                                      Administrative Charges are Verizon Wireless
          Please complete Hardware Sales Agreement               Contact Proxicast for current promotional pricing    charges, not taxes. For more details on these
                                                                                                                      charges, call 1-888-684-1888.
          Static IP Feature Support                                      One-Time Fee: $500.00
                                                                                  (See Note Below)




Rev. 111001
                                                                                                Hardware Sales Agreement
                                                                                                      with Proxicast, LLC
 312 Sunnyfield Drive, Suite 200                                                                     for Verizon Wireless
 Glenshaw, PA 15116-1936
                                                                                                                   Please E-Mail or Fax completed Forms to:
 Phone: 412-213-2477 Fax: 412-492-9386
                                                                                                                                             sales@proxicast.com
                                                                                                                                              FAX: 412-492-9386

 AUTHORIZED USER / COMPANY

 Name:        ________________________________________                        __

 Company: ________________________________________                            __

 Address:     ________________________________________                        __

              ________________________________________                        __

 Phone:       ________________________________________                        __    E-Mail:      ________________________________________                        ___


This agreement on terms and conditions of cancellation is between Proxicast, LLC and 'Authorized User' as indicated above. Authorized User has agreed to execute
a Service Agreement for cellular telephone service with Verizon Wireless and to be bound by the following additional terms and conditions set forth by Proxicast.

The parties agree as follows:

1) In the event Authorized User, for any reason whatsoever, cancels, converts or disrupts the Service Agreement for cellular telephone service with Verizon
Wireless before two hundred ten (210) days of the date of activation, Authorized User will, within ten (10) days from cancell ation, pay directly to Proxicast, LLC the
sum of one hundred fifty ($150.00) dollars for each cellular telephone number activated, as liquidated damages in consideration of discounts provided with respect
to the full retail price of cellular telephone equipment sold in conjunction with said wireless Service Agreement . Disruption of service includes theft of telephone or
other communications device, relocation of Authorized User, or involuntary termination of service for failure to make timely payments to Verizon Wireles s. This
cancellation fee is in addition to any charge for early termination set forth in the Service Agreeme nt.

2) Authorized User further agrees not to cancel, convert or disrupt any current service which is presently active on Verizon Wireless for two hundred ten (210)
days from the date of activation. Conversion from an alternative service provider to Veri zon Wireless is acceptable; however, it is the Authorized User's
responsibility to cancel such existing alternative service. Proxicast cannot cancel such service for Authorized User.

3) In the event it is necessary to enforce this agreement through lega l action, Authorized User agrees to pay a reasonable collection expense of one hundred fifty
($150.00) dollars. In addition, any expenses or costs incurred by Proxicast, LLC, in enforcing its rights under this agreement, including attorney's fees, shall b e
paid by the Authorized User.



In my individual capacity and on my own behalf of the entity I represent, if any, I acknowledge that I have read and understa nd all of the terms and conditions of
this document and agree to be bound thereby.

If signing on behalf of an entity, I represent that I am a duly authorized representative of the entity shown under Authorized User (above) ; and I have submitted
this application in the capacity indicated as my Title below. If I am representing a corporation, I acknowl edge that the execution of this document has been
authorized by all necessary corporate action.



AUTHORIZED USER (Print)                     _____________________________________________________________


SIGNATURE                                   _____________________________________________________________


TITLE                                       _____________________________________________________________


DATE:                                       _____________________________________________________________




 OFFICE USE ONLY:
 Device Model: _______________________                   ESN: _______________________ _______                    MDN: _____________________________


Rev. 111001

								
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