House of Reps Customer Order Request Form


Requestor's Information

*Office Name:

*State/District:

*Account #:

*Authorized Contact Name:

*Email:

Phone:



Order Information


If you are in need of ordering multiple lines, please include that information in the 'additional notes' field below.


*New Number Needed (provide area code, city, state):

Upgrade (provide current number):

*User Name:

*Device (specify color and size if applicable):

*Price Plan (e.g. 400 shared voice and data bundle or other):

Accessories:

Pickup from Longworth HOB - provide Person Authorized to Pickup in box below:
Yes
No

Ship to Address, Attn and Phone:

Additional notes:



Acknowledgement

By submitting this order, you agree to billing any incurred charges to the account.

Please acknowledge acceptance below.

*Required Field