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Name:
Company Name:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone:  (ex. 555-555-5555)
Alternate Phone:  (ex. 555-555-5555)
Fax:  (ex. 555-555-5555)
Email Address:
Confirm Email Address:
Web Address:
Type/Nature of Business:
Year your business started:
How many employees do you have?
Do you have a retail location?
Yes No
Number of locations?
How soon would you like to begin?
Within 30 days
Two (2) months
Three (3) or more months
Do you currently have access to a computer or the Internet at your business?
Yes No
How do you intend to generate LocalNet customers? (select all that apply)
Current leads
Website traffic/Banner ads
Inbound/Outbound telesales
In-store advertising
Advertising (electronic or print)
Other
Estimated new LocalNet customers per month:
Are you currently working with another ISP to provide internet access to your customers?
Yes No
If yes, who is the ISP and what services are provided by the ISP?
Would you provide your own marketing materials?
Yes No
What type of materials do you think would help generate sales in your retail store?
Please print, fill out, and fax the W-9 form to (716) 632-2745 after submitting your application. Your application will not be processed without completion of the W-9 form. Please use a cover sheet with ATTENTION: RESELLER PROGRAM.

Purpose of Form
Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee.
A person who is required to file an information return with the IRS, must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.
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