CMS Request for Agency

Thank you for your interest in CMS's Agency program Please select the program you are interested in, provide the information requested, and submit the form below. Providing all information requested allows us to process your request without delay.

Thank you for your cooperation.

Please complete all sections below.

Company Overview

1. General Information:

Check One: Proprietorship Partnership Corporation

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



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
Number of years selling Telecommunications Services:
			Year(s) Month(s)
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:
Switched Long Distance:		% (of Monthly Billings)
Dedicated Long Distance:		%
Local Services:		%
Data (Frame Relay / Private Line):		%
Internet:		%
Wireless / Paging:		%
Hospitality:		%
Other 1:		%
Other 2:		%


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 the program you are submitting this form for?

Form Completed By (name):
Date:	(00/00/00)
*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 this Request Form.
We will contact you shortly after reviewing your information.