White Glove Activation Request Form

WHITE GLOVE ACTIVATION REQUEST
Accuracy is key to a speedy uninterrupted process.

Inaccuracy will slow the process and can lead to a denial.
CARRIER:
If working with a T-Mobile rep, enter their name
MOBILFY PARTNER EXPERT (MPE):
PARTNER NAME:
Eco-system Partner
MOBILFY PARTNER CODE:
Starts with "M"
WHO IS FILLING OUT THIS FORM:

First NameLast Name
5 DIGIT SALES ID:
If Unknown, 00000
DEALER CODE
If Unknown, put 0000
YOUR EMAIL:
YOUR PHONE #:
Monetization Success Program?
Owner Partner Company Name
Owner Partner Code
Starts with "M"
VOICE LINES QTY:
INTERNET PLAN?:
TV?:
MOBILE LINES:
HOME PHONE?:
HOW MANY MOBILE INTERNET LINES?:
Mobile Internet
HOW MANY BUSINESS INTERNET LINES?:
Fixed Internet or HSI
HOW MANY IOT LINES?:
SPECTRUM INTERNET EQUIPMENT?:
CONTROL CENTER?:
XOMO STREAM BOX?:
When should Self Install Kit be shipped?

MonthDayYear
Date
QTY? RATE PLAN/MRC?
NEW CUSTOMER?:
WHAT IS THE CURRENT BAN?
BAN=BILLING ACCOUNT NUMBER
WHAT IS THE CURRENT PIN?:
WHO IS PROVIDING HARDWARE?:
Is it an E-SIM Activation?
Provide E-SIM IMEIs. If multiple, add a row for each.
What device will be used? Include model and IMEI. If using multiple devices, add a row for each. (Or upload file using the upload button on the bottom of this form)
What device model will we order from the carrier? Include model, storage and color. If ordering muliple devices, add a row for each.
HOW IS THE CUSTOMER PAYING?
WHAT AREA CODE IS PREFERRED?:
If porting, porting will be done after activation.
WHAT ARE THE LINES BEING USED FOR?
Please explain the business need/proposed solution.
CUSTOMER NAME:

First NameLast Name
CUSTOMER PHONE NUMBER:

Area CodePhone Number
CUSTOMER EMAIL:
example@example.com
Customer SSN
CUSTOMER DATE OF BIRTH:

MonthDayYear
CUSTOMER SERVICE ADDRESS:
CUSTOMER SERVICE ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
HAS THE CUSTOMER LIVED HERE FOR OVER A YEAR?
PREVIOUS ADDRESS:
PREVIOUS ADDRESS:

Street Address

Street Address Line 2

CityState

Zip Code
CUSTOMER LEGAL BUSINESS NAME
Name as shown on State/Gov paperwork
TYPE OF BUSINESS
TAX ID/SSN:
If existing customer, enter 0
IF SOLE PROP, DATE OF BIRTH

MonthDayYear
DOB
IF SOLE PROP, DRIVER LICENSE NUMBER AND STATE ISSUED
NUMBER OF EMPLOYEES
If existing customer, enter 0
COMPANY WEBSITE
Customer info
FIRST NAME
Authorized Signer
LAST NAME
Authorized Signer
BUSINESS PHONE NUMBER

Area CodePhone Number
EMAIL ADDRESS
Authorized Signer
BILLING ADDRESS
Billing address
ADDRESS 2
STE or extra info
CITY
Billing city
STATE
ZIP CODE
Billing Zip code
PORTING
CARRIER ARE PORTING FROM?
WHAT PHONE NUMBER/S ARE YOU PORTING?
NAME ON CURRENT BILL
CURRENT CARRIER ACCOUNT NUMBER
PORTING/TRANSFER PIN
SAME SHIPPING?
SHIPPING ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
NOTES
Feel free to add any notes with us here.
OPTIONAL FILE UPLOAD:

Browse Files
SIM file, quotes, spec details, etc. Cancelof
Should be Empty:

WHITE GLOVE ACTIVATION REQUEST

Accuracy is key to a speedy uninterrupted process.