Personal Details
Other Details
Optional Services / Features
Bank Details ( For Direct Deposit)

First Name*

Middle Name

Last Name*

Date of Birth*

Sex*

ID Type #1*

ID Type #1 No.

ID Type #2*

ID Type #2 No.

Address*

Phone Number (Current)*

Email Address*

Occupation

Full Name of Reference #1*

Reference #1 Contact Number

Full Name of Reference #2*

Reference #2 Contact Number

Which mobile network are you with currently ?*

Digicel

bmobile

Would you like to port your existing bmobile number for use on our network?*

Yes

Do you want a new sim/digicel #?*

Yes

Activation Type*

Telephone Number (for Conversion or Renewal)

Do you want to receive company newsletter, promotional offers and other material?*

Yes

Security Question?*

Security Answer*

Optional Services*

Roaming

Data Plan

Data (GPRS/EDGE/3G)

Please Specify

Bill Type #1*

E-Bill

Paper

Bill Type #2*

Itemized

Summarized

I have read, understood and hereby agree to the Digicel terms and conditions. I hereby: (i) warrant that I am duly authorized to sign on behalf of the applicant (ii) warrant that the information provided in this application is true and correct (iii) accept the Digicel services (iv) authorise Digicel to use, release or obtain any information relating to my credit to third parties including but not limited to credit bureaus, credit insurers, registries, other companies in the Digicel Group, and other persons with whom I have financial dealings, and as otherwise may be permitted or required by law (v) authorize any person or entity that Digicel contacts in this regard to provide such information as is requested by Digicel (vi) agree to pay for any postpaid services for a minimum period of eighteen (18) months from the date of receipt of each handset and (vii) agree to remain liable for all charges incurred to my account inclusive of charges from supplemental phones on the account. I hereby acknowledge that that I was advised that there are select 4G coverage areas within Trinidad and Tobago and I confirm that based on the 4G coverage areas described, the area of my primary usage falls within such a 4G coverage area.

Full Name of Account Holder*

Name of Bank

Address of Bank

Account Number

T&T Medical Association

Digicel Postpaid Mobile Service Agreement – Individual Registration

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