New Page 2

City:

State: ZIP:

Phone:

Fax:

Email*:

Website:

Primary Contact:

Title:

Secondary Contact:

Title:

Type of business:

B2B Wireless Reseller

Retail Wireless Reseller

VAR

Other

Systems Integrator

Carrier Sales Agent

Tier 2-3 Carrier

For current wireless resellers only:

How many voice activations do you currently process per month?

How many data activations do you currently process per month?

What percentage of your applications are both voice and data?

What percentage of your business is B2B (vs retail sales)?

Which carriers do you currently resell?

Which PortNexus sub-dealerships are you interested in?

Att Sub-Dealer

Package Reseller

Associate Dealer