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Phantom Wave Wireless Sign-up
First Name: Last Name:
Mailing Address: City: State: Zip Code:
Home Phone: Cell Phone: Fax:
User Name: Hint: User name should be your last name and first initial, followed by '-w'. Example: doej-w
Password: Password should be no longer than 8 characters. No symbols other than '_' or '-'
Retype Password:
You may specify up to 5 e-mail addresses you would like to create with your account. '.' '-' and '_' are allowed.
Payment Option:
Pay Monthly
Pre-pay three months
Pre-pay six months
Pre-pay one year
Credit Card Type:
American Express
Card Number:
Card Expiration Date:MM/YY
Referred by:
Comments or Special Instructions:
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Verification Code: