CUSTOMER SERVICE APPLICATION

CUSTOMER DETAILS
FIRST NAME LAST NAME
Ronald GED
Brown
DATE OF BIRTH (DD/MM/YY) GENDER: F M
30/05/1970
ID1 TYPE: EBC ID DP PP ID2 TYPE: EBC ID DP PP

ID#: 571153 ID#:

BILLING ADDRESS Lp #129 Cassava Street, Carapichaima, TRI

SERVICE ADDRESS

MOBILE CONTACT# WORK CONTACT# FIXED LINE CONTACT# PREFERRED CONTACT METHOD

18687514334 EMAIL
EMAIL ADDRESS:
SMS

PHONE

NO PROMOTIONAL CONTACT

EMPLOYER: OCCUPATION:
N/A WORK AREA: N S E W T’GO

SERVICE REQUEST DETAILS/ORDER INFORMATION

SERVICE TYPE: INTERNET LANDLINE MOBILE SECURITY TV

I understand that if I am switching from another carrier,
that I must stay on the TSTT/Bmobile network for a
minimum of 180 days. NEW SIGN UP PLAN UPGRADE
NEW PLAN DETAILS MONTHLY FEE MINIMUM SERVICE PERIOD
I 6understand
MONTHS that this is a
B-PUMPING $295 VI
BASE PLAN_______________________________________________________ $295
_____________ 12 MONTHS
12-month contract and that
prematurely
12 MONTHSending this
ADD-ON 1________________________________________________________ _____________ contract
24 MONTHSwill incur penalty fees.
24 MONTHS
ADD-ON 2________________________________________________________ _____________ ____________________
36MONTHS
36 MONTHS
Customer's signature
PROMOTIONAL OFFER_____________________________________________ N/A
N/A
TECHNICAL DETAILS
LANDLINE TV SECURITY INTERNET

SERVICE # NUMBER OF SET TOP BOXES LANDLINE BACKUP# SELF INSTALL

TECH INSTALL

Additional costs may be incurred based on number of set top boxes

MODEM DELIVERY
MOBILE
MOBILE NO. MOBILE DEVICE TYPE MODEL
POSTPAID
18687514334 TSTT SALE Samsung
SIM NO. SERIAL NUMBER/IMEI
PREPAID DEALER SALE

121701160838437 COE
358907345737899
Bills will be sent to the emal address provided above. PAPER BILL REQUIRED Y N
PAYMENTS AND CHARGES CUSTOMER DECLARATION
RECEIPT#
HANDSET/ SIM CHARGE:

INSTALLATION CHARGE: I declare that the information on this application is true and
accurate. I have read and agreed to TSTT’s Terms and Conditions
RELOCATION CHARGE: of Service.

SECURITY DEPOSIT: I understand and agree that I must pay for any services for the
minimum service period indicated above.
ADVANCE PAYMENT:
I hereby authorise TSTT to use, share, obtain and exchange my
credit and other personal information with credit bureaus, credit
VAT:
insurers, registers, other companies in the TSTT group and other
persons and companies with whom TSTT has financial dealings,
TOTAL DUE: as well as any other person as may be permitted or required by
law. I also authorize any person from whom TSTT seeks to obtain
TOTAL PAID: information in this regard to provide such information.

BALANCE BILLABLE:

CUSTOMER NAME: CUSTOMER SIGNATURE: DATE:

RONALD BROWN 25 Mar, 2024

SALES AGENT DECLARATION
I have checked this form and herby verify that all fields on this form are complete, accurate and consistent with the documents provided.
SALES AGENT NAME: SALES AGENT SIGNATURE: CHANNEL PARTNER DATE:

VANROSS JACKSON CELLULAR PLANET WEST MALL 25 Mar, 24