House of Reps Customer Order Request Form

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Requestor's Information

*Office Name:

*State/District:

*Account #:

*Authorized Contact Name:

*Email:

Phone:

Order Information

*New Number Needed (provide area code, city, state):

Upgrade (provide current number):

If you are in need of upgrading multiple lines, please separate each phone number by a comma.

*User Name:

*Device (specify color and size if applicable):

*Price Plan (e.g. Unlimited voice/text/data/hotspot $48.75):

Accessories:

Pickup from Longworth HOB - provide Person Authorized to Pickup in box below:
Yes
No

Ship to Address, Attn and Phone:

Additional notes:

Acknowledgement

By submitting this order, you agree to billing any incurred charges to the account.

Please acknowledge acceptance below.

*Required Field

Submit