SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY PRICE EXPIRES 05/09/2013 First Name Middle Initial Last Name Customer Name: New Phone? Check Here OR Upgrade? Check Here Phone Number: _ _ _- _ _ _ -_ _ _ _ SELECT THE DEVICE YOU WISH TO ORDER iPhone 5 16GB Free with Voucher Select: BLACK or WHITE iPhone 5 32GB Free with Voucher Select: BLACK or WHITE iPhone 5 64GB Free with Voucher Select: BLACK or WHITE iPhone 4S 16GB Free with Voucher Select: BLACK or WHITE iPhone 4S 64GB Free with Voucher Select: BLACK or WHITE iPhone 4 8GB Free with Voucher Select: BLACK or WHITE Devices shown require a new-line activation (or eligible upgrade) on a plan with data, Premium Data add-on and two-year Agreement. Page 1 of 4 SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY Salesperson: Arthur Moore For Internal Use Only: Subcontractor: ____________________________ YOU MAY SELECT EITHER TOTAL EQUIPMENT PROTECTION OR APPLECARE+ TOTAL EQUIPMENT PROTECTION: Your initials here: ___ Decline, no charge Your initials here: ___ Accept, $11/month Total Equipment Protection is highly recommended. Without it, you may have to purchase a new phone at manufacturer’s suggested retail price (MSRP) if your phone is damaged, lost, or stolen. A nonrefundable deductible applies for approved claims for loss, theft, physical or liquid damage claims. APPLECARE+: Your initials here: ___ Decline, no charge Your initials here: ___ Accept, $99 one-time charge AppleCare + for iPhone benefits are in addition to any legal rights provided by consumer protection laws in your jurisdiction. AppleCare+ for iPhone is subject to acceptance of the Terms and Conditions.The company obligated under AppleCare+ for iPhone in the United States is AppleCare Service Company, Inc., an Arizona corporation and wholly owned subsidiary of Apple Inc., doing business in Texas as Apple CSC Inc. AppleCare+ for iPhone must be purchased together with new covered equipment. Purchase of the plan is not required to purchase the covered equipment. For complete details, see terms at www.apple.com/legal/applecare/applecareplusforiphone.html. Service coverage is available only for the iPhone and its original included accessories that are defective in materials or workmanship or for battery depletion of 50 percent or more from original specification. The replacement equipment that Apple provides as part of the repair or replacementservice may be new or equivalent to new in both performance and reliability. See terms at www.apple.com/legal/applecare/applecareplusforiphone.html for full details. AppleCare+ for iPhone provides coverage for up to two incidents of accidental damage from handling, each incident is subject to a $49 service fee. Local telephone fees may apply. Telephone numbers and hours of operation may vary and are subject to change. First Name Middle Initial Last Name Customer Name: Billing/Shipping Address: City State Zip Code Email Address: Videophone/ Home Contact #: Date of Birth: Social Security #: Driver’s License #: Credit Card Type: __ __ __ -- __ __ __ -- __ __ __ __ Required MM / DD / YYYY Required for credit check __ __ __ -- __ __ -- __ __ __ __ Required for credit check _________________________ State Issued: _____ ___ Visa ___ MasterCard Exp Date: MM/DD/YYY ___ American Express ___ Discover Name on the Credit Card: Credit Card #: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ MM / DD / YYYY Card Verification Code: Card Expiration Date: Page 2 of 4 SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY DEPOSIT: I understand Sprint will perform a credit check. You may be required to pay a deposit based on the credit check. If all monthly payments to Sprint are received on time, the deposit will be returned to you in 12 months. By checking below, you authorize us to charge your credit card, if a deposit is needed. If you select None, and your credit check does not pass approval, you will not receive a device without paying a deposit. I approve a deposit if needed: ____ None ____ $50 _____ $100 _____ $150 ____$250 Your initials here: _____ This indicates that I understand Sprint will perform a credit check. Please create a numeric PIN or provide your existing Sprint account PIN. Create your own 6 to 10 Digit PIN#: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Please select your security question and fill in your answer. Who is your business mentor? Favorite author? Street you grew up on? First name of childhood best friend? First pet name? First elementary school name? ANSWER: Monthly Plan—Sprint Relay Discount Plan: Sprint Relay Data Only Plan - $54.99 / month ($44.99 plus $10 required Premium Data add-on) with two-year Agreement plus taxes and any add-on options. * Not applicable for Data Cards and Tablets * DATA ONLY PLAN (Requires a two-year Agreement) While on the Sprint network:  Unlimited email  Unlimited internet access  Unlimited Instant Messaging (IM)  Unlimited domestic SMS text and Picture Messaging (MMS not included for BlackBerries) o Video text messages are not included  Incoming calls are blocked on all devices. The block is not removable on Google Android OS, iOS, and Windows OS devices. o However, on all other devices the block can be removed by contacting our video customer service ([email protected]) o If the incoming block is removed, you will be billed $0.20 / minute for local voice calls or $0.40 / minute for long distance voice calls Page 3 of 4 SPRINT RELAY STORE WIRELESS ORDER FORM FOR NEBRASKA RELAY **Monthly charges exclude taxes, Sprint Surcharges incl. USF charge of up to 16.1% (varies quarterly), Administrative Charge (up to $1.99/line/mo.), Regulatory Charge ($0.40/line/mo.) & state/local fees by area. Sprint Surcharges are not taxes or gov’t-required charges and are subject to change. Details: Sprint.com/taxesandfees. Although Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel can be used for emergency calling, such emergency calling may not function the same as traditional 911/E911 services. By using Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel for emergency calling you agree that Sprint is not responsible for any damages resulting from errors, defects, malfunctions, interruptions or failures in accessing or attempting to access emergency services through Sprint IP, Fed IP, Sprint IP using IM, and WebCaptel whether caused by the negligence of Sprint or otherwise. Featured devices may also be activated on voice plans. See Sprint Relay Representative for details and plan options. May require up to a $36 activation fee/line, credit approval & deposit. Up to $350/line early termination fee (ETF) for advanced devices & up to $200 ETF/line for other devices (no ETF for Agreements cancelled in compliance with Sprint’s Return Policy). Sprint Relay Data Only Plan: Offer ends 05/09/13. Messaging: Includes text and picture for domestic messages sent or received. Video text messaging is not included. International messages sent or received from the U.S. are $0.20/msg; international messages from outside the U.S. are up to $0.50/msg. SMS voice messages may incur an additional data charge of $0.03/KB. Data: Premium content/downloads (games, ringers, songs, certain channels, etc. are add’l charge. Text to 3rd parties to participate in promotions or other may result in add’l charges. Sprint Music Premier/Sprint Radio includes access to select radio channels and song downloads (cost varies). Sprint TV Premier includes select channels. See Sprint.com/tvguide for channel information. Content and channel line-up subject to change. Voice/Data Usage Limitation: Sprint reserves the right, without notice, to deny, terminate, modify, disconnect or suspend service if offnetwork usage in a month exceeds: (1) voice: 800 min. or a majority of minutes; or (2) data: 300 megabytes or a majority of kilobytes. Prohibited network use rules apply. See in-store materials or sprint.com/termsandconditions for specific prohibited uses. Other Terms: Coverage not available everywhere. Unless otherwise noted, Sprint 4G LTE devices will not operate on the Sprint 4G (WiMax) network; Sprint 4G (WiMax) devices will not operate on the Sprint 4G LTE network. Sprint 4G (WiMAX) network reaches over 70 markets, on select devices. See sprint.com/4G for details. The Sprint 3G Network reaches over 278 million people. Offers & service plan features not available in all markets/retail locations or for all phones/networks. Pricing, offer terms, fees & features may vary for existing customers. Other restrictions apply. See www.sprintrelaystore.com for details. ©2013 Sprint. SPRINT, the logo, and other trademarks are trademarks of Sprint and may not be used without permission. iPhone, iPod touch, and iPad are trademarks of Apple Inc. Other marks are the properties of their respective owners. Upgrading to this device may require the $10/month Premium Data add-on upon activation: Your initials here: ___ One-time $12 shipping & $36 activation fee will be included on your first bill from Sprint: Your initials here: ___ MAILING LIST: Sprint Relay may email you regarding products and services that we think may be of interest to you. You can opt out at any time. ____ Yes, add me to the mailing list ____ No, do not add me to the mailing list By signing this Sprint Application, I understand that I agree to the terms above and to Sprint’s terms and conditions for service (“Terms and Conditions”), which are located at: http://shop2.sprint.com/en/legal/legal_terms_privacy_popup.shtml. Upon my request, Sprint will provide me with a copy of the Terms and Conditions. SIGNATURE: ____________________________________________ TODAY’S DATE: __________________________________________ Sprint 14-Day Satisfaction Guarantee minus all charges based on actual usage within 14 days Note: Available only through an authorized Sprint Relay Representative Mail the completed order form with signed original voucher to: Sprint Relay Store Attention: Arthur Moore 34 Jerome Ave, Suite 220 Bloomfield, CT 06002 Questions? Send an email to [email protected] Page 4 of 4