| Rogers Wireless - New Activation Students ONLY
|
＊Incorrect info might cause delay
＊Incomplete shipping info might cause delay
|
| Membership Number |
|
| Shipping Information: |
Full Name*
FName LName |
|
| Address* |
|
| Building Entry Number |
* Buzzer#, for shipping without delay |
| City* |
|
| Province* |
|
| Postal Code* |
|
| Full billing address if different than above: |
| Address |
|
| City |
|
| Province |
|
| Postal Code |
|
| Plan Information: |
| Phone Selected* |
*Price subject to change by Rogers without notice. To inquire most up-to-date price, please contact INFO@DRAGONSABROAD.COM Or select "Not Decided".
*Price Match is also provided.
|
| Current Cell Phone Model |
|
| Plan Selected* |
Plan Details
|
| Bonus Information: *Only for new activation |
| Bonus Selected* |
|
| Contact Information: |
| Birthdate* |
( MMDDYY ) |
| Home Phone* |
|
| Work Phone |
|
| FAX |
|
| Email* |
|
| Best Time for Delivery |
|
| 2 Pieces of ID* |
1.
2.
|
| Informaion only exposes to Rogers Wireless. |
|