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 NEW
DEALER SIGN-UP FORM
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Please fill out the form below
and click submit to send us your details. *
Required Fields
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Company Name:
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*
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First Name:
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*
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Last Name:
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*
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Doing Business as ("DBA) or Other Name:
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Home Phone:
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Office Phone:
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*(enter
10 digit number without space,/,-)
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Cell Phone:
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Fax#:
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Email Id:
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*
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Address1:
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*
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Address2 :
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City :
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*
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State
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*
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Zip Code
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*
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If shipping addrss is the same
as the Address1 , check the box
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Shipping Address1
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*
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Shipping Address2
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City :
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*
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State :
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*
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Zip Code:
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*
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Company Type :
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Years in Business :
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If Corporation, State & Date or
Incorporation :
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Retailer or Distributor :
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*
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Number of Stores :
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*
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Region :
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*
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Current Wireless Providers:
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Current Prepaid Phones Sold per Month:
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Forecasted STi Mobile Handset Sales per
Month :
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