Guam - DOCOMO Pacific

Membership Type

1. New Sign Up Updating Member

1. Member Name:
2. Mobile Wireless #:
3. Mailing Address:

   (Street, City/Village, State, Zip Code)

4. Date of Birth:

   (MM-DD-YYYY)

5. Age:

Gender

1. Male Female

1. Email Address:
2. Referred By:
3. Referring member's Club Red Card#:

1. I here by certify that to the best of my knowledge and belief, the above statements are true and that I am 18 years old or above. Club Red does not sell membership information to 3rd parties. Periodically, I will receive special offers or notices on behalf its partners. I agree to receive Club Red Value-added Messages (sms, email or direct email). As a member, I am eligible to participate in Club Red "Members Only" events; and events. If I decided to opt out of receiving of receiving the Club Red Value-Added Messages, change my rate plan below the required rate plan or cancel my postpaid services with DOCOMO PACIFIC, my membership will be terminated.

Member Survey (Must be completed to certify membership)

What kind of mobile handset are you currently using?

What factors influenced your decision to subscribe to DOCOMO PACIFIFC Wireless Service?

1. Friends Parents Print Ad Radio Ad TV Ad Other:

What do you think is the most important aspect when choosing a wireless service provider?

1. Service Features Variety of Phones Customer Service Other:

How do you use your wireless phone most?

1. SMS/Texting Voice Mobile Data Service

What is your ethnicity?

1. Chamorro Filipino Caucasian Asian Spanish African American Other:

What television station do you watch most?

1. ABC NBC FOX Spike TV MTV VH1 CBS Other:

Which is your favorite radio station?

1. KStereo The Rock KUAM 93.9 Other:

What type of promotion would you like to see?

1. Phone specials Free airtime Accessory discounts Free added-value service (i.e. Data, Max) Other:

Where do you send text messages to the most?

1. Local – DOCOMO PACIFIC Local – Other Carriers Philippines U.S Other:

Do you want to receive brochures or email on our other products & services?

1. Wireless Services like SMS, MAX & BREW Long Distance Wireless Aircard

1. Type the code in the box
2. By submitting this form electronically, I hereby agree to the terms and conditions as stated above.