Modern Wireless | Create New Customer Account

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Leading the way since 1999.

Personal Information

First Name: *

Last Name: *
Email Address: *

Representative Name

Represenatative:

Business Contact Information

Legal Business Name: *
DBA (if Applicable):
Contact Name: *

Title: *
Street Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Mobile:
Email: *

Web Site:
Business Entity:

Business Information

Fed Tax Id No: *

Dun & Bradstreet No:
Date Business Commence:

How long at current Address: *
Description of Goods Sold: *
Annual Gross Sales: *
Purchaser\'s Name: *

Phone: *

Email: *
A/P Name: *

Phone: *

Email: *

Principal Information

Last, First, MI: *

Title:
Last, First, MI: *

Title:

Business Trade References

Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:
Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:
Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:

Create an Account

FOLLOW THESE INSTRUCTIONS:

A copy of Resellers Permit must be sent in along with this form. A copy of Tax Id is needed for the following states: Alaska, Montana, New Hampshire, Oregon, and Delaware.
By submitting this application, you authorize Modern Wireless, Inc. to make inquiries into the company credit history and business trade references that you have supplied.
Once completed please Fax to: (714)535-6396

Personal Information

First Name: *

Last Name: *
Email Address *
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Login Information

Password *

Confirm Password *

Select Representative

Business Contact Information

Legal Business Name: *
DBA (if Applicable):
Contact Name: *

Title: *
Street Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Mobile:
Email: *

Web Site:
Business Entity:
Corporation

Sole Proprietorship

Limited Liability

Business Information

Fed Tax Id No: *

Dun & Bradstreet No:
Date Business Commence:

How long at current Address: *
Description of Goods Sold: *
Annual Gross Sales: *
Purchaser's Name: *

Phone: *

Email: *
A/P Name: *

Phone: *

Email: *

Principal Information

Last, First, MI: *

Title:
Last, First, MI: *

Title:

Business Trade References

Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:
Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:
Company Name: *

Contact Name:
Address: *
City: *

State: *

Zip Code: *
Phone: *

Fax:

Web Site:

* Required Fields

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