CMS Request for Agency

Thank you for your interest in becoming a CMS Agent Partner.
Please provide the information requested below. Providing all information requested
allows us to process your request without delay.
Thank you for your cooperation.

Company Overview

1. General Information:

Check One: Proprietorship Partnership Corporation

Company Name:		DBA:
Street:		Street line 2 or P.O. Box:
City:		State:
Zip:		Country:
Telephone:		Fax:
Primary Contact:		E-mail:
Secondary Contact:		E-mail:


2. Officer(s) / Partner(s) / Owner(s) and Titles:
Name 1:		Title 1:
Name 2:		Title 2:
Name 3:		Title 3:
Name 4:		Title 4:

3. Personnel Information:
# of Employees:		# of Sales Personnel:
# of Sub-Agents:
Primary Geographical Territory:

Marketing Overview

4. Agency / Company Experience:

Are you a Master Agent?

Yes No

No. of years in telecommunication:

Current Telecommunications Provider(s):

1)	2)	3)
4)	5)	6)
7)	8)

Monthly Billings: USD $ (please round to the nearest dollar)

Average Customer Size: USD $ (enter "20,000" for twenty thousand)

How do you market Telecommunications Services?


5. Products Sold: Enter % of Monthly Billings
DIA:	Voice:	MPLS:
Integrated:	Hosting/Co-Location:	Wireless:
Point to Point:	Local:	Conferencing:
Other:


Miscellaneous Information
6. Other:
Are you involved in any additional business other than Telecommunications? Yes No
If Yes, please specify:	How did you hear about our company?

Please enter any additional comments in the space provided below:

Please expedite this request and contact me as soon as possible.

Thank You for submitting your request to become a CMS Agent Partner.
We will contact you shortly after reviewing your information.