Affiliate Member Information

I understand this cellular phone service is a benefit provided to me as a member of the Arizona Police Association (APA). If my status as a member should change, I further understand I must forfeit this service and assume personal responsibility for my phone account within 14 days. Further, in the event my membership terminates, I will be responsible for any charges due and owing at that time. I agree to guarantee prompt payment of my Verizon Wireless account by securing amounts due to be charged to my credit/debit card monthly; if my account were to go 30 days past due Verizon Wireless will suspend/cancel services and require full payment to resume services.

Date*

Do you already have an APA/Verizon account?*

APA/Verizon Account Number*

ex... 0123479868-01234

Are these new/existing lines?*

Name*

First Last

Email*

Contact Phone*

Member Association*

Location

Station

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Verizon ProfileID

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Approval Contact Email

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address (for new devices)*

Same as Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you are only adding New Phone Lines. You may skip this step.

What are we moving?

Account Information (Transferring from)

Transfers

Service Provider	Name on Account	Account Number	Actions

There are no Transfer from Accounts.

Service Provider*

Name on Account*

Account Number*

PIN*

Billing Address on Your Statement*

Same as Previous Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Lines to Transfer From Account*

Existing Phone # to Transfer/Add

Phone Type (Brand/Model & Size & Color)

Device Insurance ($4.15/month)

Move a Smart Watch

Yes

IMEI

Phone

Phone# (If moving a Jetpack)

Add New Lines

Choose a Device...*

Thank you for completing your application. Please press the 'Submit' button below.

Automatic Card Payment Information

I hereby authorize Verizon Wireless to automatically charge my credit card each month. This authorization applies to the credit card number listed below and any future cards that I may designate by calling Verizon Wireless. I understand that Verizon Wireless reserves the right, upon notification, to terminate my participation in this payment option. My participation in this payment option is subject to Verizon Wireless’ approval. I understand and agree that Verizon Wireless is not liable for erroneous bill statements or incorrect charges to my credit card, except that should an error in the bill statement occur, Verizon Wireless will be responsible to correct it if Verizon Wireless receives notice from me of this error within 90 days.

Card Billing Address*

Same as Previous Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name (as shown on card)*

Type*

Visa

Master Card

Discover

Diners Club

American Express

Card Number*

CVC# (security code on back)*

Exp Date*

Signature*

Please sign below to affirm your understanding of all above terms and conditions presented and that you agree to the financial obligation described.

Name

This field is for validation purposes and should be left unchanged.

Your Account

Wishlist

Account Settings

Your Account

Wishlist

Account Settings

Your Account

Wishlist

Account Settings

PORAC

PSPRS

Account

Arizona Police Association

Verizon Wireless Service – Add/Transfer Form

Affiliate Member Information

If you are only adding New Phone Lines. You may skip this step.

What are we moving?

Account Information (Transferring from)

Add New Lines

Thank you for completing your application. Please press the 'Submit' button below.

Automatic Card Payment Information

Our Association

Membership

Customer Support

Arizona Police Association