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Authorized Agent Information

To learn more about becoming an Authorized Agent of Verizon Wireless please complete the information below so that a Verizon Wireless Account Manager may contact you.

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First Name*	Mailing Address 1*
Last Name*	Mailing Address 2
Name of Business*	City*
Phone Number*	State* Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip*
Mobile Phone Number	Do you offer wireless service? No, we do not Yes, we offer wireless services If yes, which carrier(s)?
Fax Number
Email*
Verify Email*
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