Please provide the following contact information:

Name
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Please provide your account information:

User Name
Password
Confirm Password

Please enter requested cancel date, if other than immediately, and reason for cancellation or other comments:

To cancel a Mobile Broadband Account, please submit this form and return your device and all its original contents to Millenicom at the Portland, OR address (1735 SW Miles, Suite 2000, Portland, OR 97219). If you have purchased your device, no need to return it.

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