Agent Sign Up Form

Your One-Time Agent Set Up Fee of $297 Includes:

• Web Based Wireless Phone Activation Portal
• Ecommerce enabled Retail Phone Web Site
• New Agent Training
  
• Access to Very Low Cost Wholesale Phones
  
• Email Support
  
• Phone Support
• The Latest News on Specials, New Resources, Products & Services

NOTE: Please complete the form below and CHECK FOR ACCURACY. If any part of this form is

incomplete or contains inaccurate information, you will be redirected back to this form to correct it.

Once you have submitted your information, you will be taken immediately to a confirmation page.

If you continue to have trouble, please email info@masterwirelessagent.com for support.

Contact Information
	First Name:*
	Last Name:*
	Address:*
	City:*
	State:*
	Postal(Zip) Code:*
	Primary Phone:*
	Email:*
	Click here if your billing address is the same as your mailing address:
Billing Address
	Billing Address:
	Billing City:
	Billing State:
	Billing Postal(Zip) Code:
Credit Card Information
	Card type:*	Select Card Type VISA MasterCard AMEX Discover
	Card Number:*
	Expiration Month:*
	Expiration Year:*
	Card Code (CVC):*
Purchase
	Master Wireless Agent New Dealer Sign Up
	Amount:	$297.00 – One-Time Fee