New Customer Activation Form

New Customer Activation Form

Welcome to Helix Wireless. In order to ensure a great customer experience, please complete this form and send it back to your Helix Wireless contact.

Today's Date

New Account Owner First and Last Name

New Account Address

Street Address, City, State and ZIP Code ( Include Apt or Suite)

How Many Lines

Select or enter value

Current Wireless Provider

Select or enter value

First Line

Mobile Number Line 1

Provide number if porting or type "Request New Number" to

User Name Line 1

Port Request Information Line 1

Provide Account number and Transfer PIN (if applicable)

Name on Port Out Account - Line 1

If different then New Account Information provided above

Address on Port Out Account - Line 1

Street Address, City, State and ZIP Code ( Include Apt or Suite)

if different from the above

New Device Purchase - Line 1

Provide Device Name and Model Number(s) wanting to order

Bring Your Own Device - Line 1

Provide IMEI of your existing device

Helix Wireless Plan - Line 1

Select or enter value

Second Line

Mobile Number Line 2

Provide number if porting or type "Request New Number" to

User Name Line 2

Port Request Information Line 2

Provide Account number and Transfer PIN (if applicable)

Name on Port Out Account - Line 2

If different then New Account Information provided above

Address on Port Out Account - Line 2

Street Address, City, State and ZIP Code ( Include Apt or Suite)

if different from the above

New Device Purchase - Line 2

Provide Device Name and Model Number(s) wanting to order

Bring Your Own Device - Line 2

Provide IMEI of your existing device

Helix Wireless Plan - Line 2

Select or enter value

Third Line

Mobile Number Line 3

Provide number if porting or type "Request New Number" to

User Name Line 3

Port Request Information Line 3

Provide Account number and Transfer PIN (if applicable)

Name on Port Out Account - Line 3

If different then New Account Information provided above

Address on Port Out Account - Line 3

Street Address, City, State and ZIP Code ( Include Apt or Suite)

if different from the above

New Device Purchase - Line 3

Provide Device Name and Model Number(s) wanting to order

Bring Your Own Device - Line 3

Provide IMEI of your existing device

Helix Wireless Plan - Line 3

Select or enter value

Fourth Line

Mobile Number Line 4

Provide number if porting or type "Request New Number" to

User Name Line 4

Port Request Information Line 4

Provide Account number and Transfer PIN (if applicable)

Name on Port Out Account - Line 4

If different then New Account Information provided above

Address on Port Out Account - Line 4

Street Address, City, State and ZIP Code ( Include Apt or Suite)

if different from the above

New Device Purchase - Line 4

Provide Device Name and Model Number(s) wanting to order

Bring Your Own Device - Line 4

Provide IMEI of your existing device

Helix Wireless Plan - Line 4

Select or enter value

Fifth Line

Mobile Number Line 5

Provide number if porting or type "Request New Number" to

User Name Line 5

Port Request Information Line 5

Provide Account number and Transfer PIN (if applicable)

Name on Port Out Account - Line 5

If different then New Account Information provided above

Address on Port Out Account - Line 5

Street Address, City, State and ZIP Code ( Include Apt or Suite)

if different from the above

New Device Purchase - Line 5

Provide Device Name and Model Number(s) wanting to order

Bring Your Own Device - Line 5

Provide IMEI of your existing device

Helix Wireless Plan - Line 5

Select or enter value

Confirmation of Terms and Condition

Confirm Acknowledgement of *Terms and Conditions*

Terms and condition can be found in the "Helix Hub" - Employee Handbook

Type Full Name to Acknowledge Terms and Conditions

Send me a copy of my responses

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