TRISTATE TELECOM - New User Registration

Tel: (718) 783-6262
Tel: (800) 223-4534 Fax: (718) 783-2416

New Dealer Signup

Thu Sep 9, 2010

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New Dealer Signup Form

Would you like to become a Tristate Telecom dealer? If so, please fill out the form below to get started.

The labels in bold are required fields.

Billing Info

Legal Business Name:

Business Trade Name-DBA:

First Name:

Last Name:

Job Title:

Street Address:

City:

State:

State/Province:

Country:

Zip/Postal Code:

(Required for USA)

Business Phone Number:

Cell Phone:

Fax:

Email Address:

(Email will be your login name)

Password:

Confirm Password:

Check this box if your shipping address is different from the billing address given above.

Shipping Address

First Name:
Last Name:
Street Address:
City:
State: State/Province:
Country:
Zip/Postal Code:	(Required for USA)
Business Phone Number:
Fax:
Email Address:

Other Info

Web Address:

Years in Business:
(Current Owner)

Nature of Business:

Authorized Purchaser:

	First Name:	Last Name:	Job Title:	Email Address:	Password:
1.
2.
3.

Payment Terms Requested:

Credit Card

Company Check

Net Terms

Where do you currently purchase your equipment?

Notes:

If you received an error message when you tried to use our secure server, sign in using our standard server. If you select the secure server, the information you enter will be encrypted.