**Federal Account Order Form**
![](media/image1.png){width="1.4618055555555556in" height="0.5in"}

+----------+---------------------------+-------+----------------------+
| **Acti   | **Sales Representative:   | **    | **Billing            |
| vation** | EDWARD ORIUWA**           | Sales | System/Outlet ID:**  |
|          |                           | ID/ E |                      |
|          |                           | Numbe |                      |
|          |                           | r#:** |                      |
|          |                           |       |                      |
|          |                           | **EJ  |                      |
|          |                           | 627** |                      |
+----------+---------------------------+-------+----------------------+
| **U      | **Mobile Number:          |       |                      |
| pgrade** | 240-687-1744**            |       |                      |
+----------+---------------------------+-------+----------------------+
| **Other  | **Fax Number:             |       | **ACE#      **       |
| :     ** | 240-568-1993**            |       |                      |
+----------+---------------------------+-------+----------------------+
| **EWI    |                           |       |                      |
| Profile  |                           |       |                      |
| I.D.     |                           |       |                      |
| (M       |                           |       |                      |
| andatory |                           |       |                      |
| for Navy |                           |       |                      |
| CNI):    |                           |       |                      |
| 131996   |                           |       |                      |
| extended |                           |       |                      |
| p        |                           |       |                      |
| rofile** |                           |       |                      |
+----------+---------------------------+-------+----------------------+

**Orders will not be processed unless a "Government Contract Type" is
selected!**

  -----------------------------------------------------------------------
  **Government Contract Type:**

  **Purchase Order #:**      
  -----------------------------------------------------------------------

  ------------------------------- ---------------------------------------
  **1. Agency Address:**          **2. Shipping Address: (No P.O.
                                  Boxes)**

  Name of Agency:                 Name of Agency: doc/noaa/NA02ACT65006

  P.O. Box:                       Street Address: 1315 EAST WEST HWY
                                  CIO/OPS2

  Street Address:                 Building / Suite #: ROOM 9846

  Building / Suite #:             City / State / Zip: SILVER SPRING, MD
                                  20910

  City / State / Zip:             Attention: DIANA TOWNSEND

  Attention:                      Phone #: 3017133330 X 208

  Phone #:                        **\*Check here if same as billing
                                  address**:      

  **3. Billing Address: (Complete 
  only if different from Agency   
  Address)** **\*Check here if    
  same as Agency Address above**  

  Agency Name / Address / P.O.    
  Box:                            
  ------------------------------- ---------------------------------------

  ------------- -------------- ----------- --------------- ------------- ------------- --------------------- -----------
  **Equipment                                                                          **Equipment Billing   
  Bill of                                                                              Information (Choose   
  Sale:**                                                                              One)**                

  **Qty:**      **Product:**   **DYMAX     **Reason        **Unit        **Price:**    **1.** **Purchase     
                               Code:**     Code:**         Price:**                    Order \#**: **     ** 

  **1**         **AIRCARD**    **V620**                    **\$0.00**    **\$0.00**    **2. Bill to Acct     
                                                                                       #:**                  
                                                                                       **518272523-00001**   

  **    **      **     **      **     **                   **\$     **   **\$     **   **3. Credit Card      
                                                                                       Information (if       
                                                                                       applicable)**         

  **    **      **     **      **     **                   **\$     **   **\$     **   Name of Agency:       
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Name on Credit Card:  
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Credit Card Type:     

  **    **      **     **      **     **                   **\$     **   **\$     **   Credit Card #:        
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Expiration Date:      
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Amount to be Billed   
                                                                                       to Credit Card:       
                                                                                       \$**     **           

  **    **      **     **      **     **                   **\$     **   **\$     **   Date of Price Quote:  
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Signature: **     **  

  **    **      **     **      **     **                   **\$     **   **\$     **   Printed Name:         
                                                                                       **     **             

  **    **      **     **      **     **                   **\$     **   **\$     **   Phone #: **     **    Date:
                                                                                                             **     **

  **    **      **     **      **     **                   **\$     **   **\$     **                         

  **    **      **     **      **     **                   **\$     **   **\$     **                         

  **    **      **     **      **     **                   **\$     **   **\$     **                         

  **    **      **     **      **     **                   **\$     **   **\$     **                         

  **    **      **     **      **     **                   **\$     **   **\$     **                         
  ------------- -------------- ----------- --------------- ------------- ------------- --------------------- -----------

+------------+---------+--------+-----------+-----------+-------------+
| **Account  | **Add   | **     | **Group   | **IBAS    | **Divisio   |
| \#**       | to      | Create | ID/Tie    | MAC       | n/Hierarchy |
|            | exi     | New**  | Code**    | Code**    | Info**      |
|            | sting** |        |           |           |             |
+------------+---------+--------+-----------+-----------+-------------+
| 51827      |         |        | FSDOC     |           |             |
| 2523-00001 |         |        |           |           |             |
+------------+---------+--------+-----------+-----------+-------------+
| **Enhanced | Mo      | Text   | Other:    | Other:    | Other:      |
| Features** | bileWeb | Mes    | **     ** | **     ** | **     **   |
|            |         | saging |           |           |             |
|            | Rate:   |        | Rate:     | Rate:     | Rate:       |
|            | **      | Rate:  | **     ** | **     ** | **     **   |
|            |      ** | **     |           |           |             |
|            |         |     ** |           |           |             |
+------------+---------+--------+-----------+-----------+-------------+

+-----------------------------------------------------------------------+
| **Comments:** **BILL TO ACCOUNT 518272523-00001**                     |
|                                                                       |
| **     **                                                             |
+-----------------------------------------------------------------------+

+---------------------------------------------------------+------------+
| **5. Authorization Signature:      **                   | **Date:**  |
|                                                         |            |
| **     **                                               | **041505** |
+---------------------------------------------------------+------------+

  ------------ ---------- -------------- --------- ----------- --------- ----------- -----------
  **Mobile \#  **ESN**    **Activation   **Price   **Monthly   **Promo   **Model**   **User
  (Desired                or Upgrade**   Plan \#** Access**    Code/                 Name**
  NPA-NXX)**                                                   BGSA**                

  **1**.                                 53575     \$79.99     504       V620        NOT
  3017879296                                                                         SPECIFIED

  **2.**                                                                             

  **3.**                                                                             

  **4.**                                                                             

  **5.**                                                                             

  **6.**                                                                             

  **7.**                                                                             

  **8.**                                                                             

  **9**.                                                                             

  **10**.                                                                                 

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  ------------ ---------- -------------- --------- ----------- --------- ----------- -----------