House of Reps Customer Order Request Form

Requestor's Information

*Office Name:


*Account #:

*Authorized Contact Name:



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):


Pickup from Longworth HOB - provide Person Authorized to Pickup in box below:

Ship to Address, Attn and Phone:

Additional notes:


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

Please acknowledge acceptance below.

*Required Field