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Company Name

Contact

Address

City

State

Zip

Phone

Email Address

Website

Number of Employees

Annual Revenues

What is your core business?

Are you currently an agent for another telecom provider? Yes: No:

If so, who?

What are your reasons for wanting to do business with National Telecom?

How many local lines would you target per month?

Are you interested in being a Master or Sub-Agent? Master: Sub Agent:

What state/states do you do business in?