SERVICE BILL TO: 0 MERCHANT DIRECT 0 ISO/AGENT



Communication Type: FORMCHECKBOX GSM/HSPA FORMCHECKBOX LTEPromo Code: FORMTEXT ????????DEVICE INFORMATIONDevice Serial: FORMTEXT ?????SIM #: FORMTEXT ?????IMEI (Required for LTE): FORMTEXT ?????PLANS[Select one] FORMCHECKBOX Plan 1 FORMCHECKBOX Plan 2 FORMCHECKBOX Plan 3 FORMCHECKBOX Plan 4 FORMCHECKBOX Plan 5Megabytes (MB) per month12510UnlimitedBASIC PROVISIONSEstimate approximately 75 transactions per 1MB of data usageEMV transactions and cellular device updates consume additional data and may affect transaction countsDownloading applications or configuration updates may use significant kilobytes or megabytes of dataCellular usage in excess of plan allocation is rounded up and billed at $3.95 per MB on all plansData usage cannot exceed 1GB in any monthPlans are subject to a $25 activation feePlans may be subject to early termination feesPricing is exclusive of applicable taxes and roaming chargesPrices are subject to change upon 30 days noticePlans are subject to Nexgo Wireless Terms and ConditionsSIGNATUREYour signature below confirms that you have read and agreed to be bound by all associated pricing, provided by Nexgo along with all Terms and Conditions that can be found at nexgo.us.DBA Name: FORMTEXT ?????Signature: FORMTEXT ?????Print Name: FORMTEXT ?????Date: FORMTEXT ?????AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH, DEBIT OR CREDIT CARD CHARGE)Company or Customer Name: FORMTEXT ?????Taxpayer ID #: FORMTEXT ?????Bill to Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Bill to Phone: FORMTEXT ?????Bill to Email Address: FORMTEXT ?????I (we) hereby authorize Nexgo, Inc., hereinafter called COMPANY to initiate debit entries to my (our) FORMCHECKBOX Checking / FORMCHECKBOX Savings Account (please provide copy of a voided check) / FORMCHECKBOX Credit Card (check one) at the depository financial institution named below, hereafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of U.S. law.Bank Depository Name: FORMTEXT ?????Branch #: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Routing Number: FORMTEXT ?????Account Number: FORMTEXT ?????Credit Card Type: FORMCHECKBOX Visa FORMCHECKBOX MasterCard FORMCHECKBOX American Express FORMCHECKBOX DiscoverCredit Card Number: FORMTEXT ?????Credit Card CVV: FORMTEXT ?????Expiration Date: FORMTEXT ?????This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.Name(s): FORMTEXT ?????Signature(s): FORMTEXT ?????NOTE: DEBIT AUTHORIZATION MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION.PLEASE RETURN ALL REQUIRED FORMS TO NEXGO VIA FAX OR EMAILFax: 949.266.5658 Email: orders@nexgo.us Toll Free: 866.392.8326 ................
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