PrepaidWORX | The world of prepaid, in the palm of your hand

Merchant Form (STEP 1)

Owner First Name*

Owner Last Name*

Contact Phone Number*

Email Address *

Business Full Street Address*

Suite or Building #.

City

Zip

State

Company Name*

DBA(if any):

1. Do you currently or have you ever offered any Lifeline services? Yes No

2. Have you ever distributed or sold True Wireless products? Yes No

3. Do you currently offer other prepaid wireless products and services? Yes No

4. What type of business are you?

5. How many locations do you have?

6. Do you have a storefront?

7. Your customer demographics are?

8. Does your store have high speed internet?