ePay Wireless - Registration Thank you for your interest in the ePay Wireless Cellular Dealer Referral Program. After submitting the following form you will receive a Referral Dealer Contract necessary for the completion of your activation as a participant in the program. There is no cost to become a registered referral partner, nor are there any obligations or minimums. Please complete all of the fields that pertain to your situation. Dealer Code: Prepared By: Business Name: Contact Name: Telephone Number: Alt. Phone Number: Fax Number: Email Address: Address: City: State: Zip Code: Network Affiliations: Nextel Verizon Sprint PCS Cingular/AT&T T-Mobile Alltel If Other, Please List: Nationwide Dealer?: Yes No Multi-Store Franchise?: Yes No If Multi-Store, How Many Locations: Name Of Franchise: Comments: