*Company Name:
*Website:
* Primary Contact:
* Title:
* Address:
Address 2:
* City:
* State:
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* Zip:
* Phone Number:
*E-mail:
*Business Type:
Please Select Integrator Aggregator Reseller Agent Master Agent Other
How many years in Business:
Brief description of your business:
Does your firm provide single sourcing for billing to your customers? Yes No
Does your firm provide single sourcing for
24x7 Customer Care? Yes No
Staffing - Summarize the resources you currently have
Resource
Count
Sales Reps
Sub Agents
Sales Support
Revenue – Please detail your company’s most recent breakdown by product or service
Service
% of Total
Basic Voice Services (B1s, Trunks, Centrex)
Basic Data Services (DSL, Frac T1s)
Complex Circuits (PRI, T1, Frame, Ethernet)
Wireless
VOIP
Other (Specify)
Additional value added services your firm provides customers:
Market Focus:
Your primary coverage areas:
Please Select Local Regional National Global
Customer Focus:
Please Select Large Business Mid-size Business Small Business SOHO Consumer
How did you hear about the TWCBC Partner Program?
