Activation/Rebate Request Form for Cisco 3G Devices

To activate your Cisco 3G device on the AT&T, Sprint, or Verizon Wireless networks, and receive your Cisco 3G Product Rebate, please complete this form and hit the “Submit” button at the bottom of this page.

 Note:  Items in bold are required fields.
 

Solution Provider Contact Information:
First Name:
Last Name:
Title:
Company:
Federal Tax ID:
	Without Dashes (example: 123456789)
Years In Business:
Work Phone:
E-mail:
Street Address 1:
Street Address 2:
City:
State:	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
	Zip:
Preferred Carrier:	Verizon Wireless Sprint AT&T Bell (Canada)
Preferred Carrier Account#:	(if known)
Description of your business:
Cisco Value Added Reseller Contact Information:
First Name:
Last Name:
Title:
Company:
Work Phone:
E-mail:
Street Address 1:
Street Address 2:
City:
State:	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY      Zip:
Cisco Sales Order#:
Distributor:	Cisco Westcon TechData Qwest Adtran Other Regen Anixter D&H Distributing XO Communications Clearwire Quantum
Distributor Sales Order#:
Device Type (e.g. Cisco 3G HWIC):
Please Provide the or ESN/IMEI information here (list one per line):
ESN(s) / IMEI(s):
Rebate
Send Rebate To:	Customer VAR Other
Misc
Notes:
Submitting Order. Please wait.

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