Resources - Unified Connection

Partners Application

New Sub Agent Company Name

Sub Agent Company Phone Number

Year Company Established

Sub Agent Company Number of Employees

Sub Agent Company Address

Address Line 1

Address Line 2

City

State

Dun & Bradstreet D U N S Number

If you do not have a D&B number, you can obtain one here

Main Corporate Contact Name

First name

Last name

Main Corporate Contact Title

Main Corporate Contact Email

Main Corporate Contact Phone

Main Corporate Contact Address Same?

Yes No

Main Corporate Contact Month and Day of Birth (MM/DD)

Sub Agent Company Stakeholder(s)

How many Principals/Owners owning 20% of Sub Agent’s company?

Do you want others to have access to commission reports and other sensitive documents?

Yes No

Signature

Wireless Registration

Company Name

Account ID (if current VzW customer)

Opportunity Name

Type of Order (New,Existing,Upgrade)

Contact

Title

Phone Number

Email

Address

Address Line 1

Address Line 2

City

State

Zip

Web Site

Teaming

Yes No

If Yes, Vz Rep Name

Competitive Data

Other

Estimated New Monthly Charges $

Proposed Solution

Number of Sites or new WLS activations

Number of WLS upgrades

Additional Information

Wireline Registration

Company Name

Account ID (if current VzW customer)

Opportunity Name

Type of Order (New,Existing,Upgrade)

Contact

Title

Phone Number

Email

Address

Address Line 1

Address Line 2

City

State

Zip

Web Site

Teaming

Yes No

If Yes, Vz Rep Name

Competitive Data

Other

Estimated New Monthly Charges $

Proposed Solution

Number of Sites or new WLS activations

Number of WLS upgrades

Additional Information