New Dealer Information Form
Company Name *
Your answer
DBA Name (if applicable)
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Owner First Name *
Your answer
Owner Last Name *
Your answer
Email Address *
(IMPORTANT: This will be your portal login)
Your answer
Phone Number *
Your answer
Cell Number *
Your answer
Company Federal Tax ID (FEIN)
Your answer
Do you have a VidaPay ID? *
If yes, please provide:
Your answer
Do you have an InComm ID? *
If yes, please provide:
Your answer
If No, would you like your TSP to be VidaPay or InComm? (If unsure please leave blank)
Your answer
Are you interested in Prepaid (COD) or Postpaid (ACH)? *
Products you are interested in? (check all that apply) *
Required
If you are interested in TracFone, are you interested in:
Sales Rep Name (if known)
Your answer
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