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Authorized Service Provider Application

To be considered as a VITAL Authorized Service Provider, please fill out the information below and select submit. Your application will be reviewed by our Field Services department upon receipt.

General Company Information

Company Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Web site:

Number of Employees:

1-5

6-10

11-15

16 or Over

Number of Technicians:

Length of Time in Business:

Years Months

Percent of Work Subcontracted to Other Vendors:

0-10%

11-20%

> 20%

Onsite Response Time: (Check all that you can supply)

7x24

2 hrs.

4 hrs.

NBD

Union Affiliation: (Check all that apply)

None	IBEW	CWA	NECA
Other

Coverage Areas:

Center Zip Code and Radius of Coverage from Zip Code:
(If your company can cover multiple locations, please list the various
center zip codes and their radius.)

Zip Code:		Radius Covered: (in miles)

Support Capabilities

Please check the types of equipment your company has the ability to service:

Data Communications/Telecommunications Equipment:

	Routers		Switches
	CSU/DSUs		Frame Relay Devices
	ISDN Devices		Phone Systems
	Wireless		Network Servers
	VoIP Devices		Data Storage
	DSL Devices

Cable & Wiring:

Data

Voice

Fiber

Please check the manufacturers your company is certified/authorized to perform service on:

Manufacturers:

	Adtran		CAC
	Cisco		Paradyne
	Kentrox		Telco
	Expand		Juniper
	Nortel		Verilink
	Tasman
	Other

Please list any technician certifications (i.e. A+, Network+, MCDE, CCNA, etc...):(Separated by commas)

Do you have technicians with Cisco certifications?

Yes

If so, how many?

Submitter Information

Name:

Title:

Phone:

E-mail:

(E-mail)

By submitting this application to VITAL, you certify that the information is truthful and accurate to the best of your knowledge and authorize VITAL Network Services to verify the information provided.

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