tbi-signup-form-2

Your Name

Company Name

DBA/Other Trade Name(s), Holding Co., etc.

Type of Entity (Corp., Individual, Partnership, LLC, etc.)

Type of Business (Wholesale/Retail, etc.)

State of Incorporation

Federal Tax ID No.

FCC Registration No.

FCC Registration Name

FCC 499 Filer ID No.

Name of Entity with 499 Filer ID

Tax Exempt (A Tax Exemption Package will be sent for completion prior to production)

Yes No

Legal Compliance Contact Name

Email

Website URL

Main Telephone No.

Fax Number

Headquarters Physical Address

Billing Address

Check Box if address is same as headquarter address

Other Associated Physical Street Address(s)

Previous Addresses (past 5 years)

Other Associated Physical Street Address(s)

Trade References

Company

Contact Name

Phone/Email

Company

Contact Name

Phone/Email

Company

Contact Name

Phone/Email

All Form Fields Below Are Required.

1. Has Customer or any controlling person of the Customer been the subject of a lawsuit or the subject of any other law enforcement action by any state or federal agency because of its business practices?

Select Yes or No For Number 1

Yes No

If the answer to the question above was Yes, please explain

2. Customer has implemented the STIR/SHAKEN Authentication Framework or has a documented and approved (by its requisite corporate authority) plan to implement the STIR/SHAKEN Authentication Framework no later than June 30, 2021, unless changed pursuant to applicable legislation, or a successor authentication framework if subsequently mandated by applicable federal law or regulation.

Select Yes or No For Number 2

Yes No

3. Does the Company represent and warrant that it has not engaged in any illegal spoofing?

Select Yes or No For Number 3

Yes No

4. Are any calls originated by your organization subject to the FCC’s TCPA rules, FTC’s Telemarketing Sales Rule (TSR) provisions and or the FTC’s Do Not Call (DNC) Registry?

Select Yes or No For Number 4

Yes No

5. If your organization’s calls are subject to the TCPA, TSR or the DNC Registry, please certify your organization can comply now, and going forward, with applicable Federal and State Telemarketing rules and regulations.

Select Yes or No for Number 5

Yes No