Modem Registration Form
 Date:

Please Complete this form, click submit to send and give us a call with your additional information.
Subscriber Name:  
Address:City:
State: Zip Code:
Phone 1:   Phone 2:

Current Email:  

Social Security # : ENTER "123" - Give Real # verbally over the phone

Date of Birth:     Credit / Debit:

Credit/Debit Card Number:

Exp Date:   Security Code: ENTER "123" - Give Real # verbally over the phone

Name on Credit or Debit Card:

 Card Address:City:State:Zip Code:

Drivers License Number:    State:

Account Name:   Password: (4 to 8 digits)

Secret Word:     

Modem Mac AddressPlan: *see note below

signal:  Referral or Promotion Code: (Impact, dex, radio, who referred you?)

Notes:

Questions:

Directions:

I am aware this Clearwire modem is programmed for Premium service and other service plans are available. A2Access allows me to try the service to verify adequate signal is available. If I love it, I keep it and choose which service plan I will use. The information I have supplied above can be used to activate this modem for my service plan in 24 hours unless I call to cancel. If adequate signal is not available, this modem will be returned, in the same condition as I received it, with all property of Clearwire in proper working order. 

I further acknowledge and agree that I will be responsible and will pay for any damage to or loss of the modem and/or equipment up to $240.00.

 I accept these Terms of Service.

VoIP Internet Phone Service Registration   <- Check box to Add Internet Phone
Phone Adapter MAC address example: 000E08EC7907 (12 characters)
911 Address Look up USPS 
   Customer Signature:  Initials:
   Customer Name:   Date: Date activated:  

 

* Please Note: Some markets are Clearwire with 1.5 & 2 MB Internet Service

Some Markets are CLEAR with 1, 3 or 6 MB Internet Service

getconnected@A2Access.com