Zig Solutions Inc.
#14, 10909 - 106 St
Edmonton, Alberta, CANADA
T5H 4M7

Customer Name:                                                                                                                                                                   

Company:                                                                                                                                                                               

Address:                                                                                                                                                                                 

City:                                                        Prov/State:                                            Postal/Zip:                                             

Telephone: (              )                                                          Email:                                                                                      

Referred by:                                                                                    

Primary Phone Info

ESN*:                                                                                    Cell Number: (           )                                                         

SID #**:                                                                                Service Provider (ex AT&T)                                             

 *Your ESN number is found usually underneath the battery.  It will be printed alongside your model number.  It is an 11 digit numerical number.  It may also be printed as an 8 digit hex number containing the letters A thru F.  It should also be stated on your original contract that you signed with your provider.
**System Identification number is a 1 to 5 digit number identifying your system network.  You may need to contact your provider for this info.

Pricing in Canadian Funds                                                                                          Each          Qty                Total

Emulation Programming                                                                                               $250                            $                   
                                                                
Other / Accessories                                                                                                                                          $                   

3 Watt Bag Phone                                                                                                                                             $                   

Shipping / Handling                                                                                                                                          $                  

                                                                                                                                              GST    7%             $                  

                                                                                                                                                                Total  $                   
Method of payment:
                  Enclosing a certified check or money order payable to Zig Solutions Inc.
                  Payment made by paypal ( account   sales@zigsol.com  ) 

Certification: Under penalty of perjury and fraud I hereby certify that I am the user activated by my carrier company (Cellular Service Provider) for the above Cellular Telephone Electronic Serial Number and Telephone Number. I hereby authorize and empower Zig Solutions Inc. as my agent to perform the emulation to the purchased cellular phone as required on my behalf, including phone(s) supplied by me. I further certify that all equipment connected to this line will be used in a legal manner and hereby agree to indemnify Zig Solutions Inc. of all liabilities and responsibilities which may be incurred by the use or non-use of this line, phone, equipment, emulation, and enhancements without reservation  Disclaimer: Zig Solutions Inc. hereby reserves the right to make changes to it's products to improve reliability, function, or design. Furthermore Zig Solutions Inc. does not assure any liability arising out of the application, use or non-use, or of any local, state, or federal laws, of it's products or services provided by hereby; nor does it convey any license under it's patents, copyrights, or software. In no instance shall the Zig Solutions Inc. liability exceed the amount paid by the user. Copyright infringement and theft of services are federal crimes carrying serious felony penalties. Violators will be vigorously prosecuted to the furthest extent of the law.  I authorize Zig Solutions Inc. to provide the above mentioned service. I understand, and have read the above certification and disclaimer. I certify, I am not employed by or acting for any carrier or government agency with the intent to entrap in any manner the company Zig Solutions Inc. or it's employees. 

Please Sign and Date: 
Authorized User (sign)                                                                                                            Date: