Please complete the following application and click Submit Application when completed.

Company Information
Company Name:
Owner's Name:
Address:
City:
State:	Select one... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon ----------------------- Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming
Zip:
Phone:	Ext:
Fax:
Email Address:
Website:
Company Type:	Corporation Sole Ownership Proprietorship
Business References
NAME ADDRESS PHONE ACCOUNT 1 2 3 4 5
I authorize by O Mobile PCS, Inc. and/or its assignee to request a credit history on the above listed company or trade.