Business Name (required)
Address (required)
Email (required)
Mobile Number (required)
Account Type (required) Prepaid AccountACH Account
Rep Owner (please specify) (required)
Confirm Prepaid Master TSP/Platform (required): LWPVerizonRT2/ATTCricketGenMobileUltra Mobileh2oPayments only to Emida- Payments only
Existing AT&T Prepaid dealer or New? (required) ExistingNew
If existing, confirm Branch ID:
Welcome/ Training Call (required): YesNo
Training Call Date and Time:
Onboarding App Signatures Call Date and Time:
Select Welcome Kit Desired (required): LWP KitVerizon KitCricket KitGenMobileRT2/AT&T KitFreeUp Kith2o KitUltra Mobile KitLyca KitEmida Posters
Additional Notes
Upload Emida App (required):