application form

Contact No : 0572236001 Date 04/13/2018 15:17:13

Subscriber Details:
Name of applicant Mr./Mrs./Ms.: Chaker Khalifa

P.O Box Emirate: Sharijah Nationality: Sudanese

Document Type: UAE ideinty card

Idenity No: 1115482164201 Date of issuance: 10/01/2017 Expiry Date: 09/01/2019

008: Cender: Male Working No:

I would like to receiver SMS update about Etisalat promotions: Y Email Address: Chakerkhalifa@outlook.com

Account Number: 0572236001 Request Type: Account management

Service Information:
Service Description Rental PrePayment Action

iPhone X, 12 months 185 185 Added

Advanced Payment 0 1000

VAT Exetded

Device Details
SIC Code: Description Device IMEI :

3820202331 Apple iPhone X, 64GB, Silver 353045098685645

Bill Information

Bill Cycle Address Line 1 Address Line 2 PO Box Email Will be send on )

1st of the month - - 29535 Chakerkhalifa@outlook.com

Your authorization
Terms and Condition Agreed

Employe Signature
Original document seen and verified with the
Customer Signature Company Retail Shop Stamp copy submitted

For official use only

New Request No: 0572236001 Code: Rc00 Store code: SH Sales staff: Sultan

Request No: 558383180 invoice No: 705918875 Paty ID: 30364035 Authorised management
Signature