Customer Information

Legal Name:
D/B/A:
Address:
City:
State:
Zip:
County:
Phone #:
Fax #:
Email Address:

Officers

Name: Title Cell #
Name: Title Cell #
Contact #1: Title Cell #
Contact #2: Title Cell #

Product Interest

DISH Network Exede (Satellite Broadband) Sirius XM Radio
HughesNet (Satellite Broadband) Satellite Installation Materials Sony Mobile Electronics
Consumer Electronics Products RingCentral (VOIP Phone Systems) Digital Watchdog (Surveillance Products)

Location

Retail Store Front: (Y) (N)
Future Location (if different): Store Office Other

Counties of Operation:


Company Information:

Number of locations:
Number of Employees:
Number of Installers:
Are installers subcontractors? (Y) (N)
Business Start Date:
Full Time: (Y) (N)
Projected Number of Systems installed per month:

Information about your company including industry experience: