Orion Mobile Dealer Sign Up Packet

Sub-Dealer Candidate Information For Company Pre-Approval
Carrier Sign Up List (Subject to Carrier Approval)*

T-MobileUltra MobilePaymaster PortalEpay
Company Rep*
Sub-Dealer Business Name*
DBA (If Any)
Sub-Dealer First and Last Name*
Sub-Dealer Title*
Email*
example@example.com
Date of Birth*
Social Security Number (Must Enter SSN. Application will not be processed without it)*
Federal Tax ID Number*
Sales Tax / Certificate of Authority
Business Tax Classification*

Individual/Sole ProprietorSingle Member LLCC CorpS CorpLimited Liability CompanyPartnershipTrust/Estate
Home Address *

Street Address

Street Address Line 2

CityState

Zip Code
Business Address*

Street Address

Street Address Line 2

CityState

Zip Code
Business State of Formation*
State of Store Location

NYINLAMAMSVAOther
How many locations do you own?

1 Location2 Locations3 Locations4+ Locations
Type of Business
Years in Business*
Work Phone
Mobile/Home Phone
Bank Name i.e (Chase,BOA)*
Bank Address*
Bank Routing Number*
Bank Account Number*
Identification (i.e License, Passport, Permit, State ID)

Cancelof
Voided Check

Cancelof
Articles of Incorporation/Formation

Cancelof
Business License/Tax Exemption Certificate

Cancelof
Today's Date*

MonthDayYear
Date
Sub-Dealer Signature*

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Sub-Dealer Candidate Information For Company Pre-Approval