Employee End-User Fax Form

Please follow the steps below:

Step 1: You must read and agree to the terms of this form by signing below
Step 2: Print this form by clicking on the Print button above
Step 3: Fax BOTH the form and one of the proof of employment documents below to

Acceptable Proof of Employment Documents:

  • Employee badge
    • Must contain employer's name and employee's first and last name.
  • Paystub
    • Please black-out: salary, tax amounts, banking information and Social Security Number before providing document.
      Date must be visible when scanned. Paystub should not be more than 60 days old from the date of submission.

For members of our military, please do not submit your military ID. Instead, provide any of the following:

  • Paystub
  • Veteran's ID card
  • DD Form 214

Employee documentation must include your first and last name.

(Note: Please be sure to black out personal information such as your social security number, salary information and bank
account information)

Terms and Conditions
  • You understand that your employment with the organization identified below may permit you to obtain wireless service (on eligible calling plans with a monthly access fee of $34.99 or higher)** and equipment at a discount provided you meet the other requirements set forth in the Verizon Wireless Customer Agreement.
  • You understand that this discount is based on your organization's agreement with Verizon Wireless, or the Verizon Wireless Government Employee Discount Program, and that from time to time, your discount rate may be adjusted in accordance with your organization's agreement or changes to the Government Employee Discount Program
  • You understand that the terms and conditions of the Verizon Wireless Customer Agreement apply to this employee discount program.
  • You agree that, if you are otherwise subject to an Early Termination Fee, you will not be permitted to terminate your service without being liable for such Early Termination Fee solely because of a change in your rates resulting from either a discount adjustment to which your organization has agreed or, if applicable to you,changes to the Government Employee Discount Program.
  • You understand that certain information relating to your service, including your name, your mobile telephone number and total monthly charge may be released to your organization (does not apply to Government Employees).
  • Verizon Wireless reserves the right to require proof of your employment (Company ID badge or pay stub). If a review of your employment status reveals that you are not, or are no longer, an employee of your organization, Verizon Wireless reserves the right to remove this discount and move you to a commercially available calling plan or to a non-discounted service plan for the remainder of your line term commitment.
By signing this form or, if returning via e-mail, by clicking the box to the left, you understand and agree to the terms and conditions above as well as the terms and conditions of the Customer Agreement. Employee
Name: Date:
Organization Name:
Wireless Phone Number:
Email Address:  
Phone Number where we can contact you (if different from your Wireless Phone Number):
*Government employees (or employees that do not possess or cannot submit an employee ID) may submit a pay stub no greater than 30 days old (please delete account and salary information) **Up to five (5) of your Verizon Wireless lines are eligible to receive the employee discount & they must be on the same account. Family Share Secondary lines are NOT eligible for discounted rates. Visit My Verizon at www.verizonwireless.com or contact Verizon Wireless Customer Service at 1-800-922-0204 if a price plan change is required. The discount will be applied in 1 to 2 billing cycles.
For Verizon Wireless Use Only
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