MobileCharge, provided by Infintech

Referral Form

Date
Referred By*

Contact Name*
Business Name*
Address*
City*
State*
Zip Code*
Day Phone*
Evening Phone
Email
Preferred Contact Method*

Does business currently accept credit cards? Yes
No
Current Wireless Provider?

Please list the intended number of devices for MobileCharge use.
Device Types	Currently Own	Need to purchase

BlackBerry 71xx

BlackBerry 72xx/75xx

BlackBerry 81xx/Pearl

BlackBerry 83xx/Curve

BlackBerry 87xx

BlackBerry 88xx

Comments

Do you have questions about MobileCharge™ products or services? You can find answers quickly in the Frequently Asked Questions section.