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*Note: Please provide our team with as much information as you can so we can better serve you! Fields in blue bold are required

Company Information
Company Name
Alternative Name (DBA)
Address
Address 2
Address 3
City
State
Zip/Postal Code
Country
Phone
Toll Free
Fax
E-mail
Company website
Contact Information
Salutation
First Name
Middle Initial
Last Name
Job Title
Department
E-mail
Phone
Mobile Phone
Fax
How did you hear about TelePacific?
If you selected Agent Manager, referral, or other, please provide a name or source.
Business Information
Year Established
Legal Structure of your Business?
If other Legal Structure, please specify
Revenue for last fiscal year
Marketing Information
How does your company market your current products/services offerings?
(check all the apply)
Direct Sales    
Indirect Sales    
Online Sales    
Direct Mail    
Telemarketing    
Core Business
What is your core business?
(check all the apply)
Consultant Software Vendor
Systems Integrator Reseller
Real Estate Solution Provider
OEM System Builder
Hardware Vendor Retailer
Other    
If other, please specify
Product/Service Focus
Your Product/Service Focus?
(check all the apply)
Voice Services E-Commerce
Data Services Telecom Equipment
Internet Access Consulting
Web Hosting Other
If other, please specify
TelePacific Products
Which products are you interested in selling?
(check all the apply)
  Voice Products   Data Products
Local/Long Distance Flex T-1
Prepaid Minutes Internet T-1
Flex T-1 (voice and data) Bonded T-1
Dedicated LD Colocation
Point-to-Point Web Hosting
Conference Calling Network Protection
Vertical Markets
Which vertical markets do you sell to?
(check all that apply)
Manufacturing Media
Accounting Small/Medium Business
Education Enterprise
Medical Desktop Publishing
Financial Communications
Industrial Other
Government - Local/Municipal Architect
Government - State/Provincial Builders
Legal Government - National
Publishing Hospitality
Partnership Information
Other Agent Relationships
Are any of these relationships exclusive?
Market Coverage
How would you characterize your market coverage?
(check all that apply)
Local/Metropolitan National
State Multi-National
Regional    
Number of Employees
Administrative
Direct Sales
Management
Marketing
Sub-Agents
Technical
Total Number of Employees
Comments
Comments
 

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