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Callcentric Agent Program Application

Please complete the following form to apply to become a Callcentric Agent.
Please fill in all fields on the form. We need this information to calculate your commission.

CALLCENTRIC ACCOUNT CREDENTIALS

Username *:

Password *:

You must have a Callcentric account to complete the Agent Program Application. You can create an account here and then come back to this page and submit this form.

CONTACT INFORMATION

Title *:

First Name *:

Last Name *:

Company Name:

Position:

Telephone *:

Email *:

Address 1 *:

Address 2:

Address 3:

City *:

State *:

Zip/Postal Code *:

Country *:

QUESTIONS

Please describe any businesses you are involved in today (check all that apply):

	Calling cards reseller
	Call shop
	Broadband phone services reseller
	Equipment reseller
	Wholesale telecom
	Other telecommunications services:

Where do you plan to advertise/promote the Callcentric service *?

Geographical areas (Countries, Regions, Cities)

Internet websites (please list sites)

Any specific ethnic groups

Other

How will you promote the service? (check all that apply) *:

	Word of mouth
	Internet advertising
	Sales people
	Newspaper/magazine
	Other (please describe):

How involved do you plan to be in setting up and helping your customers? (check all that apply) *:

	I will place a link on my website
	I will setup, maintain and support my customers
	I will help my customers that do not have credit cards with payments
	I will create and maintain my customers accounts by myself
	Other:

Please provide customer projections as to the number of paid subscribers (any rate plan other than IP Freedom) you believe you will have at the following intervals:

1 month
2 month
6 month
1 year


* - field required