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MMG New Distributor Application
Today's Date
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Month
-
Day
Year
Date
Which campaign(s) are you interested in adding?
*
GenMobile
Excess
Assurance
Spectrum Internet
ACA Healthcare
Contact Name
*
First Name
Last Name
Company Name
*
Contact Title
*
Contact Cell Number
*
Contact Email Address
*
Company Website (if applicable)
Primary Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary State of Business?
*
AL
AK
AZ
AR
CA*
CO
CT
DE
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
Additional state(s) your company does business in (if applicable)
*
Use abbreviation: TX, MS, NC, etc
How long has your company been established?
*
1-4 Years
5-9 Years
10+ Years
How does your company market (check all that apply)
Street Team / Table-Top Events
Door-2-Door
Online: Facebook Groups, Instagram
Online: Google Search/Banner Ads
Brick & Mortar / Retail
Business-To-Business (B2B)
Other
Company Experience (check box for each industry segment)
*
CURRENT Campaign
PAST Campaign
NO EXPEREINCE WITH
Lifeline/ACP
Internet/Cable/Sat
Solar
Dereg Utilities
Medical/COVID
Other
Please add any additional information, feedback, questions here. We'll be in touch soon. Thank you, Mobile Management Group, LLC
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