Wireless Savings and Connection Intake Form

Complete this secure Wireless Savings and Connection Intake Form. 210Hookup can review your current phone bill, device, data needs, and monthly budget.

We will use your answers to identify wireless options that may better fit your needs and help guide you through the transition.

The regular price for this service is $49.

Discounted Online Price: $25 plus applicable tax

Your selected carrier’s monthly service charge is separate and will be paid directly to the carrier.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Email *

Phone Number *

Comment or Message

ZIP Code *

Preferred Contact Method *

• Text message
• Email
• Telephone call only if necessary

Best Time to Contact YouMorningAfternoonEveningContact me by text or email only

What do you need help with? *

• My phone bill is too high
• I want a lower-cost wireless plan
• I need an affordable phone
• I want to keep my current phone
• I want to keep my current telephone number
• I need help understanding my data usage
• I need help with an eSIM
• I need help with a physical SIM card
• I need help transferring my number
• I need help setting up a new wireless account
• I am not comfortable using carrier websites
• I need help for more than one line
• Other

Who is your current wireless provider? *— Select Choice —AT&TT-MobileMetro by T-MobileVerizonBoost MobileStraight TalkConsumer CellularAnother providerI do not currently have serviceI am not sure

How many telephone lines are on your current account? *

What is your approximate total monthly phone bill?Under $25$25–$49$50–$74$75–$99$100–$149$150–$199$200 or moreI am not sure

Does your current bill include a phone payment? *

• Yes
• No
• I am not sure

Does your bill include phone insurance?

• Yes
• No
• I am not sure

Are there additional charges you want us to review? *

• Device payment
• Insurance
• International service
• Hotspot add-on
• Extra data charges
• Tablet or watch line
• Premium support
• Taxes and fees
• I am not sure
• Other

How much mobile data do you normally use each month? *

• Less than 2 GB
• 2–5 GB
• 6–10 GB
• 11–20 GB
• 21–50 GB
• More than 50 GB
• I am not sure

How do you use your phone? *

• Calls and text messages
• Email
• Social media
• YouTube or video streaming
• Music streaming
• GPS and navigation
• Banking applications
• Work applications
• Video calls
• Gaming
• Mobile hotspot
• International calling
• Other

Do you need mobile hotspot data?

• Yes, regularly
• Yes, occasionally
• No
• I am not sure

Do you need international calling or roaming? *

• Yes
• No
• I am not sure

What is your preferred monthly wireless budget? *

• $10–$15
• $16–$25
• $26–$40
• $41–$60
• I am flexible if the value is better
• I am not sure

What matters most to you? *

• Lowest possible monthly price
• More mobile data
• Reliable calling and texting
• Mobile hotspot
• Keeping my current number
• Keeping my current phone
• Customer support
• International features
• Best overall value

Do you already have a phone you want to use? *

• Yes
• No, I need to purchase a phone
• I have a phone, but I may need another one

Phone Brand *— Select Choice —SamsungAppleMotorolaGoogleOnePlusNokiaTCLOtherI am not sure

Phone Model *

Exact Model Number

On many Samsung phones, go to Settings → About Phone. Example: SM-A136U1

IMEI *

Dial *#06# on the phone to locate the IMEI.

IMEI2

IMEI2 may help determine eSIM or dual-SIM capability.

Is the phone unlocked?

• Yes
• No
• I am not sure

Does the phone support eSIM?

• Yes
• No
• I am not sure

Does the phone have a physical SIM-card slot?

• Yes
• No
• I am not sure

Do you still owe money on this phone?

• Yes
• No
• I am not sure

Do you want to keep your current telephone number? *

• Yes
• No, I want a new number
• I am not sure

Is your current number active? *

• Yes
• No
• I am not sure

Is your current number active? *

• Yes
• No
• I am not sure

Do you have your current carrier account number? *

• Yes
• No
• I need help finding it

Do you have your transfer or port-out PIN? *

• Yes
• No
• I need help obtaining it

Have you already canceled your current service? *

• Yes
• No

If “Yes” is selected: A telephone number may be difficult or impossible to transfer after the old service has been canceled. We will review the situation before recommending the next step.

How much online help will you need? *

• I can complete the carrier website while following instructions
• I need 210Hookup to walk me through every screen
• I need 210Hookup to help enter my information
• I am not comfortable using a computer
• I only need the recommendation
• I am not sure

Do you have access to email? *

• Yes
• No
• I need help creating an email address

Number keep Model

Can you receive text-message verification codes? *

• Yes
• No
• I am not sure

Do you have access to another phone or device during setup? *

• Yes
• No
• I am not sure

Would you like information about any of these services?

• Affordable Samsung phone
• Phone case
• Screen protector
• Charger and cable
• Data transfer
• Contact transfer
• Photo and video transfer
• Google account setup
• Samsung account setup
• Email setup
• Application setup
• Senior-friendly phone setup
• Child phone and parental controls
• Phone troubleshooting
• Trade-in or upgrade
• None at this time

Service Fee Acknowledgment *

• I understand that the 210Hookup fee pays for wireless research, bill review, device evaluation, plan comparison, transition guidance, device configuration, and technical assistance.

Carrier Payment Acknowledgment *

• I understand that wireless plans and monthly carrier charges are separate from the 210Hookup fee and are paid directly to the selected carrier.

Recommendation Acknowledgment *

• I understand that 210Hookup may present more than one option and that I will receive the carrier identity, plan price, features, and important terms before I enroll.

Referral Disclosure *

• I understand that 210Hookup may receive authorized referral compensation from certain participating providers.

Accuracy Acknowledgment

• I confirm that the information submitted is accurate to the best of my knowledge.

Privacy Acknowledgment

• I authorize 210Hookup to use the information I submit for the purpose of evaluating wireless options and providing the services I purchased.

Signature or Type Full Name *

210Hookup Wireless Savings and Connection Service Regular price: $49 Introductory online price: $25 Applicable taxes: Calculated at checkout Payment methods: Credit or debit card PayPal Square Stripe Other supported online payment method Payment should be completed before the form is submitted for processing.

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