Referral Partner

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Referral Partner Program

Step 1 - Sign Up

Enter your personal information

First Name

Last Name

Address 1

Address 2

City, State, Zip

Phone Number

(Format 999-999-9999)

Fax Number

Business Name

Federal Tax ID#

Legal Status of Business

I acknowledge that in order to participate in the Deltacom Referral Partner Program, I must be operating as a business and not as an individual. Deltacom reserves the right to review my business status at any time during the term of my contract.
Agree Disagree

Describe your business

How long have you been in business?

IAre you a Deltacom Cusotmer?

Yes No

How did you learn of the program?

Describe where your referrals would originate.

How many referrals would you expect to provide in an average month?

Are Deltacom services in some way related to your business?

Yes No

What is your familiarity with telecommunications voice and data services?

Do you have a lead you would like to submit once approved?

Yes No

Formal or informal reciprocity, financial or through other means of value, for exchange of lead information is prohibited.

In what city will most of your leads reside?

Email Address

Enter a valid email address

Retype Email Address

Enter the same valid email address

Are you working with a deltacom representative?

Yes No

Representative Name

Please take a moment to download and complete this W-9 Form. This form will need to be faxed to 256-264-0581 before your application can be considered.

Tax Information (You are now beginning the W-9 form)

Full Legal

As it will be reported on a federal tax return

Street Address

City, State, Zip

Each company must register by this unique company ID for tax purposes. Please verify your
information before you proceed*

* Please exclude dashes from the EIN

Business Type	Tax Identification
Corporation	EIN	Reportable Name
Partnership* *The reportable Tax ID# is the partnership's Employer Identification # (EIN)	EIN	Reportable Name

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This site provides information for ITC^DeltaCom and its subsidiaries. For investor information concerning ITC^DeltaCom, Inc., including its filings with the Securities and Exchange Commission, please use the "Investors" link above. Copyright © 2010 Deltacom, Inc. All rights reserved.