KYC Sales Agent(Required)George DinsdaleKeith MoranKerry GarrisonDavid AldworthDoug FunchDoug DavisOtherCompany Name(Required) DBA/Other Trade Name(s), Holding Co., Etc Entity Type(Required) Corporation Individual Partnership LLC Other Business Description / Provider Type(Required) VOIP Hosted PBX Conference Call Wireless Carrier Call/ Contact Center Facilities Based Long Distance Provider Other Company Address(Required) Headquarters or Main LocationAddress 2 City State Zip / Postal Code Country Billing Address Same as above Billing Address Billing Address 2 Billing City Billing State Billing Zip Billing Country Previous Addresses (past 5 years)Main Telephone No: Fax Telephone No: Website URL: State of Incorporation Years Incorporated Years in business FCC Registration Number FCC Registration Name (if differs from Customer Name) FCC 499 Filer ID Number Name of Entity w/499 Filer ID (if differs from Company Name) Tax Exempt(Required) Yes No Federal Tax ID Number (FEIN): Does your business have any certifications that permit or allow pre-recorded messages to be delivered to your customer base? Yes No Certificate UploadAccepted file types: jpg, jpeg, png, gif.Contact InfoMain Contact Name(Required) Main Contact Phone(Required) Main Contact Email(Required) Legal Compliance Contact Name Legal Compliance Contact Phone Legal Compliance Contact Email Billing (AP Contact) Name Billing (AP Contact) Email Billing (AP Contact) Phone ComplianceAre you a carrier, IPES, Interconnected Voip or Service provider that handles customers that are not your own If so, fill out the following otherwise please certify that I AM A END USER AND DO NOT PROVIDE TELEPHONY SERVICES OR MESSAGING I AM NOT A PROVIDER OF TELEPHONY SERVICES FOR END-USERS OTHER THAN MY OWN USE Do you have a Subscription Account Number (SAN) for accessing the National Do Not Call Registry? Yes No SAN Account Number Do you have a Subscription Account for the Reassigned Number Database? Yes No RND Account Number Do you have a Subscription Account Number For the Do Not Originate (DNO) database? Yes No DNO Account Number Do you have a Robocall Mitigation Plan on file with the FCC? Yes No N/A Please provide fCC ID Number if different from above: SignatureCustomer affirms and certifies that all information and answers to questions herein are complete, true and correct to the best of signatory’s knowledge and belief. Teliax retains the right to deny credit or close the account whenever it deems necessary. It is understood and agreed that an investigative report may be made whereby information is obtained through personal interviews with third parties, such as credit reporting agencies, business associates, financial sources, or others with whom the applicant is acquainted. This investigation is not limited to the references listed in this application. This inquiry may include information as to the applicant's capacity, general credit reputation, business character, and other information we deem necessary to make a sound credit decision. Name First Last Title Date MM slash DD slash YYYY