Careers
|
Investors
|
Customer Service Center
|
Agent Login
Home
Step 1 - Sign Up
Step 2 - Create Login
Referral Partner Program
Step 1 - Sign Up
Enter your personal information
First Name
Last Name
Address 1
Address 2
City, State, Zip
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
-Select a Business-
Agriculture
Communications
Construction
Finance
Insurance
IT Consultant
Network Consultant
Real Estate
Systems
Non-Profit
Retail Trade
Wholesale Trade
How long have you been in business?
-Select an option-
0 to1
2 to 4
5 to 10
10 Plus
IAre you a Deltacom Cusotmer?
Yes
No
How did you learn of the program?
-Select an option-
Website
Deltacom Employee
Friend
Deltacom Customer
Current Deltacom Referral Partner
Describe where your referrals would originate.
-Select an option-
Your customer
Your business associate
Others
How many referrals would you expect to provide in an average month?
-Select an option-
0 to 2
3 to 5
6 to 10
10 Plus
Are Deltacom services in some way related to your business?
Yes
No
What is your familiarity with telecommunications voice and data services?
-Select an option-
All
Local Voice Service
LD
internet
Data Network
Telephone System
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Solutions
|
Equipment
|
Agents & Partners
|
About Us
|
My Account
Privacy Policy
|
Regulatory
|
Terms and Conditions
|
Legal Notices
|
Industry Relations
|
Site Map
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.