New Device Request 
 

Welcome to our “Freshened” Subsidized Request Form!

We have streamlined this process by capturing all required information in one place.

Some reminders:
  • If all required information is not filled in, your request may be delayed or not processed.
  • Scroll over the green “?” for helpful hints on a field.
  • Please do not submit for a 2nd device for a store that already has one. For exception requests, please contact your RSM or Director to discuss with Approver.

Welcome to our “Freshened” Subsidized Request Form!

We have streamlined this process by capturing all required information in one place.

Some reminders:
  • If all required information is not filled in, your request may be delayed or not processed.
  • Scroll over the green “?” for helpful hints on a field.
User Type:  
Sales Representative Information
Sales Rep First Name * Sales Rep Last Name *
Email Address *  Phone *
Address *   City *
State * Zip Code *  
 
   
Customer Informatiom
Internet Connection   
Wi-Fi Available   
Store Name * First Name * Last Name *
Store Address * City * State *  Zip Code *
 
Phone Number * Email Address  * 
Sales Representative Information
   
First Name * Last Name *
Email Address * Phone *
Shipping Information
Email Address * Phone Number * Address *
City * State * Zip/Province *  
 
 
Add Device* Total Device:  0
 
Submit Request