New Mobile Service Form

Full Name or Company Title of Applicant

Applicant Address

Nature of Business or Occupation of Applicant

Service Date

SIM Security Check

Your Pet's Name

Your Mother's Maiden Name

Your Mother's First Name

Your Mother's Date of Birth

Your Date of Birth

I would like to have the Pay monthly billed to existing Sure account number:

SIM Number

Mobile Number

IMSI Number

Full Name

Telephone Number

Email Address

Cease Date

* Note: Pay monthly packages are for three full calendar months minimum term contract. The customer may cease the contract at any time by giving not less than 7 days written advance notice of termination before the end of any calendar month.