[md-form]

    [md-raw]
    *A legally binding court recognized contract will be generated automatically after form submission.
    [/md-raw]

    [md-radio label="Service"]
    SMS Connec[/md-radio]


    [md-raw]Company Details[/md-raw]

    [md-text label="Contact Name"]
    [/md-text]

    [md-text label="Mobile Number"]
    [/md-text]

    [md-text label="Company Name"]
    [/md-text]

    [md-text label="Email Address"]
    [/md-text]

    [md-text label="Office Number"]
    [/md-text]

    [md-textarea label="Company Address"]
    [/md-textarea]


    [md-raw]Service Details[/md-raw]

    [md-radio label="Account Type"]
    StandardEnterpriseReseller[/md-radio]

    [md-checkbox label="Addons"]
    TrainingSupportUsersIntegration[/md-checkbox]

    [md-checkbox label="Licence Types"]
    CampaignAutomationInboxPremium Support (US$350/mo)[/md-checkbox]

    [md-radio label="API Access?"]
    Yes[/md-radio]

    [md-text label="# Of Messages To Start"]
    [/md-text]

    [md-radio label="Add Routes?"]
    YesNo[/md-radio]

    [md-text label="Average SMS volume/mth"]
    [/md-text]

    [md-text label="Sender Address"]
    [/md-text]


    [md-raw]Service Costs (US$)[/md-raw]

    [md-text label="Setup Fees"]
    [/md-text]

    [md-text label="Subscription Fees"]
    [/md-text]

    [md-text label="SMS Fees"]
    [/md-text]

    [md-text label="Add-Ons"]
    [/md-text]


    [md-raw]Authorization[/md-raw]

    [md-text label="Full Name"]
    [/md-text]

    [md-text label="Position"]
    [/md-text]

    [md-captcha]
    [recaptcha]
    [/md-captcha]

    [md-submit]

    [/md-submit]

    [/md-form]

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