Nationwide Program Interest Form
Which Program are you interested in?
*
RRP (Recurring Revenue Program)
Standard
Legal Company Name
*
This is the name of the business used for tax and legal purposes
Do you have a DBA name? (Doing Business As)
Please Select
Yes
No
Your DBA is what your customers would know you by and the name on your receipt or invoice. Example - Google is know legally as Alphabet corporation, but known to consumers as Google
DBA (Doing Business As)
If the legal name of the company is the same as the DBA please use the legal company name in this box
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Are you an existing Nationwide Member?
*
Yes
No
Nationwide Member ID
Products of Interest
AT&T
DIRECTV
Vivint
How do you go to Market?
Retail Store Front
Door to Door
Call Center
Internet
Service and Delivery
Do you have:
Type option 1
Type option 2
Type option 3
Type option 4
How did you hear about us
*
Submit
Should be Empty: