Intelisys Sub-Agent Access Request

Intelisys Sub-Agent Direct Access Request Form

Intelisys Sub-Agent Company Name *

Intelisys Sub-Agent Company Phone Number *

Intelisys Main Point of Contact (BDM) *

Year Sub-Agent Company Established *

Intelisys Sub-Agent Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Dun & Bradstreet D‑U‑N‑S Number *

If you do not have a D&B number, you can obtain one here:
https://www.dnb.com/duns-number/get-a-duns.html
This is required by Verizon

Intelisys Sub-Agent Main Contact Name *

First

Last

Intelisys Sub-Agent Main Contact Title *

Intelisys Sub-Agent Main Contact Email *

Intelisys Sub-Agent Main Contact Month and Day of Birth (MM/DD) *

This is used for Verizon security and password creation

How many Principals/Owners own 20% or more of Sub-Agent’s company? *

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