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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