GCN Wireless Service Request Form

*** PLEASE REVIEW YOUR RESPONSES FOR ACCURACY BEFORE SUBMITTING! ***

*** ALL PLANS MUST BE ON AUTOPAY AT TIME OF ACTIVATION! ***

*** PLEASE NOTE THAT THIS IS CURRENTLY A MANUAL PROCESS AND ACTIVATIONS CAN TAKE UP TO 48 HOURS TO COMPLETE! ***

* Required

Port a Number or Get a New Number? (Check One) *

Sponsor's Name *

Sponsor's USA Number (USA000XXXX) *

Customer Name *

Customer USA Number (if available)

Company Name *

Email Address (Must be unique for each line of service) *

Customer Home Address - NO PO BOXES (Including City, State, Zip Code) *

Customer Billing Address (if different than home address)

Customer Shipping Address (if different than home address)

Device IMEI Number (dial *#06# from device keypad) *

Do you need a new sim card? *

SIM card is free, but customer is responsible for shipping fees. (May be cheaper and quicker to purchase one locally)
 Yes No

SIM Card Number (Must be unused)

SIM Card Size to Send

 Standard Micro Nano

SIM Card Shipping Option
 Standard ($11.50 - 3 to 5 days) Overnight ($21.95 - 1 to 2 days)

Make and Model of Device *

Credit Card Number (no dashes) *

Credit Card Expiration Date *

Credit Card Security Code (3-4 digits on back of card) *

Choose Your Plan *
 Talk and Text Only (24.95) 1gb (32.95) 2.5gb (39.95) 5gb (49.95) 6gb (54.95) 7gb (59.95) 8gb (64.95) 9gb (69.95) 10gb (74.95) 2gb TABLET (29.95) 5gb TABLET (39.95) 10gb TABLET (54.95) Other :

What carrier are you porting from? (if applicable)

 T-Mobile Verizon Sprint Other :

Previous Carrier Account Number

Previous Carrier Password / Pin

Number To Be Ported

R200 Number (Admin Use Only)

Would you like to become an Independent Affiliate Marketer (I'M) with GCN? By selecting Yes, you agree to be set up on autopay for the monthly affiliate fee of $14.95) *

 Yes (You agree to be set up on autopay for the monthly affiliate fee of $14.95) No