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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.
 
Indicates a required field
 
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

Over 16
  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)
Zip Code: Radius Covered:
(in miles)
Zip Code: Radius Covered:
(in miles)
Zip Code: Radius Covered:
(in miles)
Zip Code: Radius Covered:
(in miles)
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/DSU
Frame Relay Devices ISDN Devices Phone Systems
Wireless Devices Network Servers VoIP Devices
Data Storage DSL Devices    
Cabling/Wiring:
Data Voice Fiber
Please check the manufacturers your company is certified/authorized to perform service on:
Manufacturers:
Adtran Carrier Access Cisco
Expand Juniper Kentrox
Nortel Paradyne Tasman
Telco Systems Verilink    
Other If other, please list: (Separate by commas)
Please list any technician certifications (i.e. A+, Network+, MCDE, CCNA, etc...):
Technician Certifications: (separate by commas)
Do you have technicians with Cisco Certifications? Yes No
How many technicians?
Submitter Information:
Name:
Title:
Phone:
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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