Provider Listing Form as of 7/19/4

To get a listed on the Vendors Helping Norvergence Customers page & emails to TAA's 6,000+ "Norvergence News" list, please print this page, fill it in NEATLY (so we can read it) and then fax it to 909-494-4257 along with the listing invoice. An hour after faxing it, call 206-203-6115 x1 to get the form reviewed and processed. 

Provider Name: 

Provider Email Address:

Provider Cell Phone:

Provider Mailing Address:

Business Name:

Business Phone & Extension:

Business Web Address:

Business Mailing Address (if different):

Provider Directory Listing Information - Below or on a separate piece of paper, please list the categories (yellow page headings) under which you would like to be listed. Where listings are broken out by state, please list those states under which you would like to be listed. For each category listing, please state HOW LONG you have been providing this service, HOW MANY OLD customers you have for this service and about HOW MANY NEW customers you sell for this service each month or year. Questions? Email or call TAA Administrator Kathleen Brown at kb@telecomagent.org or 206-203-6115 x2.

Fax this form and the listing invoice to 909-494-4257.