Reseller Customer Service - Become A New Agent

New Agent Registration Form

Business Name:

Contact Name:

Street Address:

City:

State:

Zip Code:

Contact Phone:

- - * ext. (no spaces)

Fax #:

Contact E-Mail:

Are you currently an agent for any other wireless carrier? Yes No	*
If 'yes' tell us which carrier:

Do you currently have a retail store?* Yes No	*
If 'yes' tell us how long: yrs

What are you interested in Selling? 1-way 2-way Both *

Comments:

Fields with * are required