Galaxy Application

Name

Email Address

Contact Phone Number

Full Street Address

Apt or unit#

City

State

ZIP

Do you currently or have you ever offered any ACP or Lifeline services? Do you currently or have you ever offered any ACP or Lifeline services? Yes No

Have you ever distributed or sold Galaxy Distribution products or services? Have you ever distributed or sold Galaxy Distribution products or services? Yes No

Do you currently have sales team? Do you currently have sales team? Yes No

If yes, How many?”

Are you part of a master agent team? Are you part of a master agent team? Yes No

Do you have reliable transportation ? Do you have reliable transportation ? Yes No

Are you willing to travel? Are you willing to travel? Yes No