Hosted SMS Consent Business Name * Name * Name First First Last Last Phone Number to be Hosted with MyRepChat * Users Email Address used for your MyRepChat Account * If user is requesting more number, please enter them here separated by “,” Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal TERMS AND CONDITIONS By signing the below, I verify that I am, or represent (for a business), the above-named service customer, authorized to change the SMS carrier(s) for the telephone number(s) listed, and am at least 18 years of age. The name and address I have provided is the name and address on record with my local telephone company for each telephone number listed. I authorize ionlake, LLC., or its designated agent to act on my behalf and notify my current carrier(s) to change my SMS carrier(s) for the listed number(s) and service(s), to obtain any information ionlake, LLC. deems necessary to make the carrier change(s), including, for example, an inventory of telephone lines billed to the telephone number(s), carrier or customer identifying information, billing addresses. Consent * I have read, understand, and voluntarily agree to take part in this training. Participant’s Signature * Clear Date * If you are human, leave this field blank. Submit Start Over
