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Mediatrix Channel Partner Online Registration Form

Please complete and submit the application form to begin the process to be considered as a Mediatrix Channel Partner.

A Mediatrix representative will review your application form and contact you with further information.

Please Note: Fields with an asterisk ( * ) are required fields.

Company Headquarter Information
*Company Name:
*Address 1:
Address 2:
*City:
State / Province:
*Country:
*Zip / Postal Code:
*Main Telephone:
Main Fax Number:
*Web Site URL:
Primary Contact Information
*Salutation:
*First Name:
*Last Name:
*Title:
*Direct Phone Number:
*Fax Number:
*Email: Please provide a valid e-mail address.
Business Information
How were you introduced to Mediatrix? Mediatrix Sales Representative Magazine advertisement Magazine editorial Mediatrix Business or Channel Partner (specify) Web Search (specify) Trade Directory (specify) Other (specify)
*How long has your company been in business?
*What is the company's annual revenue in US dollars?
*Which Mediatrix products do you expect to resell?
*How much revenue do you expect to generate in VOIP products?
*What type of products do you currently resell today?
*Which equipment vendors are you affiliated with?
*What brand or which vendor's Communications Management System (i.e. Softswitch, H.323 Gatekeeper, SIP Server or MGCP Call Agent) are you currently selling, supporting or using to provide service?
*What signaling protocol is your company currently supporting?
*How many Sales Offices do you have?
*What geographical regions does your company cover?
*Does your company provide dial tone? Yes No
If yes, please specify your type of business: (e.g. are you a CLEC, ILEC, LEC, Other?)
Please note that submission of this form neither constitutes an application by your company nor an offer by Mediatrix Telecom to establish a relationship. A Mediatrix representative will contact you with further information regarding your application.