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:
