diff --git a/forms/registration/buy_number.rb b/forms/registration/buy_number.rb
new file mode 100644
index 0000000000000000000000000000000000000000..f39be7dc0c33775b2bc6845bf08a4d7bf2049348
--- /dev/null
+++ b/forms/registration/buy_number.rb
@@ -0,0 +1,34 @@
+form!
+
+title "Purchase Number"
+
+instructions <<~I
+	You've selected #{@tel} as your JMP number.
+	This number has a one-time price of #{'.2f' % @tel.price}.
+	(If you'd like to pay in another cryptocurrency, currently we recommend using a service like simpleswap.io, morphtoken.com, changenow.io, or godex.io.)
+I
+
+field(
+	var: "activation_method",
+	type: "list-single",
+	label: "Activate using",
+	required: true,
+	options: [
+		{
+			value: "credit_card",
+			label: "Credit Card"
+		},
+		{
+			value: "bitcoin",
+			label: "Bitcoin"
+		},
+		{
+			value: "bch",
+			label: "Bitcoin Cash"
+		},
+		{
+			value: "code",
+			label: "Referral Code"
+		}
+	]
+)