Document 6462924

SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY
PRICE EXPIRES 05/09/2013
First Name
Middle Initial
Last Name
Customer Name:
New Phone? Check Here
OR
Upgrade? Check Here
Phone Number: _ _ _- _ _ _ -_ _ _ _
SELECT THE DEVICE YOU WISH TO ORDER
iPhone 5 16GB
Free with Voucher
Select: BLACK or WHITE
iPhone 5 32GB
Free with Voucher
Select: BLACK or WHITE
iPhone 5 64GB
Free with Voucher
Select: BLACK or WHITE
iPhone 4S 16GB
Free with Voucher
Select: BLACK or WHITE
iPhone 4S 64GB
Free with Voucher
Select: BLACK or WHITE
iPhone 4 8GB
Free with Voucher
Select: BLACK or WHITE
Devices shown require a new-line activation (or eligible upgrade) on a plan with data, Premium Data
add-on and two-year Agreement.
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SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY
Salesperson: Arthur Moore
For Internal Use Only:
Subcontractor: ____________________________
YOU MAY SELECT EITHER TOTAL EQUIPMENT PROTECTION OR APPLECARE+
TOTAL EQUIPMENT PROTECTION: Your initials here: ___ Decline, no charge
Your initials here: ___ Accept, $11/month
Total Equipment Protection is highly recommended. Without it, you may have to purchase a new phone at
manufacturer’s suggested retail price (MSRP) if your phone is damaged, lost, or stolen. A nonrefundable deductible
applies for approved claims for loss, theft, physical or liquid damage claims.
APPLECARE+:
Your initials here: ___ Decline, no charge
Your initials here: ___ Accept, $99 one-time charge
AppleCare + for iPhone benefits are in addition to any legal rights provided by consumer protection laws in your jurisdiction. AppleCare+ for iPhone is subject to
acceptance of the Terms and Conditions.The company obligated under AppleCare+ for iPhone in the United States is AppleCare Service Company, Inc., an Arizona
corporation and wholly owned subsidiary of Apple Inc., doing business in Texas as Apple CSC Inc. AppleCare+ for iPhone must be purchased together with new
covered equipment. Purchase of the plan is not required to purchase the covered equipment. For complete details, see terms at
www.apple.com/legal/applecare/applecareplusforiphone.html. Service coverage is available only for the iPhone and its original included accessories that are
defective in materials or workmanship or for battery depletion of 50 percent or more from original specification. The replacement equipment that Apple provides as
part of the repair or replacementservice may be new or equivalent to new in both performance and reliability. See terms at
www.apple.com/legal/applecare/applecareplusforiphone.html for full details. AppleCare+ for iPhone provides coverage for up to two incidents of accidental damage
from handling, each incident is subject to a $49 service fee. Local telephone fees may apply. Telephone numbers and hours of operation may vary and are subject to
change.
First Name
Middle Initial
Last Name
Customer Name:
Billing/Shipping
Address:
City
State
Zip Code
Email Address:
Videophone/
Home Contact #:
Date of Birth:
Social Security #:
Driver’s License #:
Credit Card Type:
__ __ __ -- __ __ __ -- __ __ __ __
Required
MM / DD / YYYY
Required for credit check
__ __ __ -- __ __ -- __ __ __ __
Required for credit check
_________________________ State Issued: _____
___ Visa
___ MasterCard
Exp Date:
MM/DD/YYY
___ American Express ___ Discover
Name on the Credit Card:
Credit Card #:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
MM / DD / YYYY
Card Verification Code:
Card Expiration Date:
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SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY
DEPOSIT: I understand Sprint will perform a credit check. You may be required to pay a deposit
based on the credit check. If all monthly payments to Sprint are received on time, the deposit will be
returned to you in 12 months. By checking below, you authorize us to charge your credit card, if a
deposit is needed. If you select None, and your credit check does not pass approval, you will not
receive a device without paying a deposit.
I approve a deposit if needed: ____ None
____ $50
_____ $100
_____ $150 ____$250
Your initials here: _____ This indicates that I understand Sprint will perform a credit check.
Please create a numeric PIN or provide your existing Sprint account PIN.
Create your own 6 to 10 Digit PIN#:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Please select your security question and fill in your answer.
Who is your business mentor?
Favorite author?
Street you grew up on?
First name of childhood best friend?
First pet name?
First elementary school name?
ANSWER:
Monthly Plan—Sprint Relay Discount Plan:
Sprint Relay Data Only Plan - $54.99 / month ($44.99 plus $10 required Premium Data add-on)
with two-year Agreement plus taxes and any add-on options.
* Not applicable for Data Cards and Tablets *
DATA ONLY PLAN (Requires a two-year Agreement)
While on the Sprint network:
 Unlimited email
 Unlimited internet access
 Unlimited Instant Messaging (IM)
 Unlimited domestic SMS text and Picture Messaging (MMS not included for BlackBerries)
o Video text messages are not included
 Incoming calls are blocked on all devices. The block is not removable on Google Android OS,
iOS, and Windows OS devices.
o However, on all other devices the block can be removed by contacting our video
customer service ([email protected])
o If the incoming block is removed, you will be billed $0.20 / minute for local
voice calls or $0.40 / minute for long distance voice calls
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SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY
**Monthly charges exclude taxes, Sprint Surcharges incl. USF charge of up to 16.1% (varies quarterly), Administrative Charge (up to $1.99/line/mo.),
Regulatory Charge ($0.40/line/mo.) & state/local fees by area. Sprint Surcharges are not taxes or gov’t-required charges and are subject to change. Details:
Sprint.com/taxesandfees. Although Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel can be used for emergency calling, such emergency calling may
not function the same as traditional 911/E911 services. By using Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel for emergency calling you agree that
Sprint is not responsible for any damages resulting from errors, defects, malfunctions, interruptions or failures in accessing or attempting to access
emergency services through Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel whether caused by the negligence of Sprint or otherwise. Featured
devices may also be activated on voice plans. See Sprint Relay Representative for details and plan options. May require up to a $36 activation fee/line, credit
approval & deposit. Up to $350/line early termination fee (ETF) for advanced devices & up to $200 ETF/line for other devices (no ETF for Agreements cancelled in
compliance with Sprint’s Return Policy). Sprint Relay Data Only Plan: Offer ends 05/09/13. Messaging: Includes text and picture for domestic messages sent or
received. Video text messaging is not included. International messages sent or received from the U.S. are $0.20/msg; international messages from outside the U.S. are
up to $0.50/msg. SMS voice messages may incur an additional data charge of $0.03/KB. Data: Premium content/downloads (games, ringers, songs, certain channels,
etc. are add’l charge. Text to 3rd parties to participate in promotions or other may result in add’l charges. Sprint Music Premier/Sprint Radio includes access to select
radio channels and song downloads (cost varies). Sprint TV Premier includes select channels. See Sprint.com/tvguide for channel information. Content and channel
line-up subject to change. Voice/Data Usage Limitation: Sprint reserves the right, without notice, to deny, terminate, modify, disconnect or suspend service if offnetwork usage in a month exceeds: (1) voice: 800 min. or a majority of minutes; or (2) data: 300 megabytes or a majority of kilobytes. Prohibited network use rules
apply. See in-store materials or sprint.com/termsandconditions for specific prohibited uses. Other Terms: Coverage not available everywhere. Unless otherwise noted,
Sprint 4G LTE devices will not operate on the Sprint 4G (WiMax) network; Sprint 4G (WiMax) devices will not operate on the Sprint 4G LTE network. Sprint 4G
(WiMAX) network reaches over 70 markets, on select devices. See sprint.com/4G for details. The Sprint 3G Network reaches over 278 million people. Offers &
service plan features not available in all markets/retail locations or for all phones/networks. Pricing, offer terms, fees & features may vary for existing customers.
Other restrictions apply. See www.sprintrelaystore.com for details. ©2013 Sprint. SPRINT, the logo, and other trademarks are trademarks of Sprint and may not be
used without permission. iPhone, iPod touch, and iPad are trademarks of Apple Inc. Other marks are the properties of their respective owners.
Upgrading to this device may require the $10/month Premium Data add-on upon activation:
Your initials here: ___
One-time $12 shipping & $36 activation fee will be included on your first bill from Sprint:
Your initials here: ___
MAILING LIST: Sprint Relay may email you regarding products and services that we think may be of
interest to you. You can opt out at any time.
____ Yes, add me to the mailing list
____ No, do not add me to the mailing list
By signing this Sprint Application, I understand that I agree to the terms above and to Sprint’s terms
and conditions for service (“Terms and Conditions”), which are located at:
http://shop2.sprint.com/en/legal/legal_terms_privacy_popup.shtml. Upon my request, Sprint will
provide me with a copy of the Terms and Conditions.
SIGNATURE: ____________________________________________
TODAY’S DATE: __________________________________________
Sprint 14-Day Satisfaction Guarantee
minus all charges based on actual usage within 14 days
Note: Available only through an authorized Sprint Relay Representative
Mail the completed order form with signed original voucher to:
Sprint Relay Store
Attention: Arthur Moore
34 Jerome Ave, Suite 220
Bloomfield, CT 06002
Questions? Send an email to [email protected]
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