Interested in becoming a Subagent

Company Information Company Common Name:* Company Common Name is already exists Company Common Name can not be empty Company Phone:* Ext.   At least 10 digits are required. Company Phone can not be empty Phone number is Invalid Company Address:* Company Address can not be empty Company Address 2: Company City:* Company City can not be empty Company State:* Please Select AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY Company State must be completed Company Zip Code:* Company Zip Code Must be a number Company Zip Code can not be empty Contact Person First Name:* Contact Person First Name can not be empty Contact Person Last Name:* Contact Person Last Name can not be empty Contact Person Email:* Contact Person Email can not be empty Email is Invalid Contact Person Phone:* Ext.   At least 10 digits are required. Phone number is Invalid Contact Person Phone can not be empty Does the subagent have or perform the following Retail Location(if yes, how many?): * YES NO   Questionnaire must be completed How many? Questionnaire must be completed Input is Invalid Mall Kiosk: * YES NO   Questionnaire must be completed Home based office: * YES NO   Questionnaire must be completed Installation teams: * YES NO   Questionnaire must be completed Event sales reps or team: * YES NO   Questionnaire must be completed Direct Mail: * YES NO   Questionnaire must be completed Print Media (news paper, magazine etc): * YES NO   Questionnaire must be completed Door Hanging\ Flyers: * YES NO   Questionnaire must be completed Inbound Call Center: * YES NO   Questionnaire must be completed Outbound Call Center: * YES NO   Questionnaire must be completed Door to Door sales team: * YES NO   Questionnaire must be completed Online/Website [if yes, list all urls]: * YES NO   Questionnaire must be completed Urls:   Questionnaire must be completed Additional Questions Have you sold Brightspeed services before? * YES NO   Questionnaire must be completed How long have you been in business? * Less than 1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years 31 years 32 years 33 years 34 years 35 years 36 years 37 years 38 years 39 years 40 years 41 years 42 years 43 years 44 years 45 years 46 years 47 years 48 years 49 years 50 years More than 50 years Questionnaire must be completed What States and or Countries do you operate in? *   Questionnaire must be completed What products do you currently sell? DirecTV: * YES NO   Questionnaire must be completed Dish Network: * YES NO   Questionnaire must be completed Cellular: * YES NO   Questionnaire must be completed Home Security: * YES NO   Questionnaire must be completed Other: How will you be selling Brightspeed services? * DEALER PREMISE DEALER OFFSITE/EVENT CUSTOMER PREMISE CALL CENTER CUSTOMER CALL IN