New Account Set Up Form

    Account Type *

    Please Choose All That Apply As It Will Populate Additional Fields.

    Company Information

    Legal Company Name *

    DBA

    Company Address

    Address Line 1 *

    Address Line 2

    City *

    State *

    ZIP Code *

    Business Address Must Match Registered Company Address.

    Tax ID Type *

    Tax ID *

    Business Type *

    D & B Number *

    Is Ship-to Address Different from Company Address? *
    YesNo

    Ship-to Address

    Address Line 1 *

    Address Line 2

    City *

    State *

    ZIP Code *

    No. of Employees *
    1-1011-5051-100101-500500-9001000+

    No. of Sales Agents *
    1-56-1010+

    Annual Sales Volume *

    Public Sector Contracts *
    YesNo

    Public Sector Contract Details *

    US Small Business Admin Certifications *
    Veteran OwnedService Disabled Veteran OwnedEconomically Disadvantaged Women OwnedMinority OwnedSmall Disadvantaged Owned (8a)Historically Underutilized Business Zone (HUBZone)Small BusinessWomen OwnedNot Applicable

    Are You Buying Equipment From Us? *
    YesNo

    Sales & Use Tax Certificate Number *

    Upload Copy of Tax Certificate *

    Will Converge IOT Pay Your Company A Commission? *
    YesNo

    Upload Copy of Tax Certificate *

    Does Your Company Have An Existing Carrier Rebill Contract? *
    T-Mobile Solution ProviderVerizon VPPAT&T APEX

    Does Your Company Sub-Contract? *
    YesNo

    Contact Information

    Primary Contact Name *

    Contact Email *

    Contact Phone Number *

    Contact Fax Number *

    Accounting Contact Name *

    Contact Email *

    Contact Phone Number *

    Contact Fax Number *

    Banking Information

    Business Address Must Match Registered Company Address.

    Bank Name *

    Name on Bank Account *

    Type Of Bank Account *

    Account Number *

    ABA Routing Number *

    Customer Focus

    Sales Territory *
    NationalRegional

    Markets *
    AllGreat LakesNorth CentralNortheastPacificSouth CentralSoutheast

    Segments *
    AllState/LocalFederalEducationNationalSmall/Medium BusinessLarge/Enterprise Business

    Services *
    Cloud IT & ApplicationsHardware & Software SalesManaged IT ServicesProfessional ServicesIOTMobility Solutions (Kits, Staging)Other

    Solutions *
    Advanced CommunicationsCloud, IT & ApplicationsInternet of ThingsNetworksSecurityMobilityOther

    Specialties *
    Energy & UtilitiesFinance & InsuranceTransportation & DistributionProfessional Services, Technology & MediaManufacturingRetail & HospitalityHealthcare

    Hardware Categories *
    Phone/HandsetRugged TabletGPS TrackerHigh Performance ComputingTabletsRugged HandsetsCameraIOTLTE Routers/GatewaysRugged Laptop

    Vendor Product Information


    Type of Vendor *
    OEMSecondary Market DistributorDistributor/ResellerDropshipperVAR

    OEM Brand *


    Product Categories *
    HandsetsTabletsRoutersHotspots/ModemsExternal AntennasSecurity CamerasAsset TrackingMDM/SaaSOther


    Brands *
    AppleSamsungLGAlcatelZTEBlackberryKyoceraSonimCATGoogleMicrosoftOther


    Additional Product Information *

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    If SSL or TLS encryption is activated, the data you transfer to us cannot be read by third parties.

    Contact Information

    Address

    3101 N Federal Hwy STE 700,
    Fort Lauderdale FL 33306

    Phone

    (888) 982-6638
    (754) 225-4467

    Email

    [email protected]