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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