Please fill in the fields below:(required fields in bold)
Company Name
Address
City
State/Province
Please Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC LB MB NB NF NS NT ON PE QC SK YT
Primary Contact
Contact Phone Number
Email
Website Address
Business Model
National VAR / SI Regional VAR / SI Telecom Agent Telecom Equipment Provider Other
If Other what Business Model
Years in Business
<5 Years 5 - 10 Years >10 Years
Total number of employees
What type of agent relationship are you interested in with Level 3?
Direct Agent Master Agent Sub Agent
Do you manage sub-agents?
Yes No
If yes, how many sub-agents do you manage?
Do you currently have a contract with a Master Agent?
Yes No
If yes, with what Master Agent?
Total Monthy Billings:
$50K - $250K $250K - $1M $1M - $5M >$5M
Total average monthly sales:
$1,000 - $5,000 $5,000 - $10,000 $10,000 - $25,000 $25,000 - $50,000 >$50,000
Please list any carriers you are currently representing:
Please list any certifications:
Transport Services
Level 3 High Speed Private Line (DS3+) Level 3 Intercity / Metro Wavelengths Level 3 Metro Ethernet Private Line Level 3 Low Speed Private Line
IP and Data Services
Level 3 Dedicated Internet Access (DIA - DS3+) Level 3 Dedicated Internet Access (DIA - DS1) Level 3 High Speed IP Level 3 IP VPN Level 3 VPLS Level 3 Ethernet VPN
Colocation and Enabler Services
Level 3 Managed Ethernet Access Level 3 Managed Security Level 3 Managed Router Level 3 Colocation
Enterprise Voice
Level 3 Network Based Internet VoIP Level 3 Enterprise IP Trunking Level 3 TDM Local Voice Level 3 Enterprise Dedicated 1+ / Toll Free (DS3+) Level 3 Enhanced Toll Free
Where did you learn about the Level 3 Business Partner Program?
Phone+ CRN VAR Business Tradeshow Other