Dealer Co-op Finance Request Form

If you are interested in participating in the American Wireless Co-Op financing Program, please complete the form below. Once completed, the information will be automatically emailed to your American Wireless Account Manager, the media company of your choice, and our internal co-op department.

You will receive an email with an approval status from our co-op department. This notice will also be sent to your American Wireless Account Manager as well as the media company.

If you are developing multiple media campaigns where you will be utilizing different media vendors, please complete this form for each request.

Important Notice: As of January 1, 2007 American Wireless will implement a new Co-op Finance policy that requires participating Agents to spend a minimum of $1,000 per pre-approval/campaign. A processing fee will also be instituted for each transaction. See Agent Co-op Fund Release Agreement for more details.

All new Dealer Co-Op Finance requests to be processed and claimed within the current quarter must be submitted by the 15th day of the last month of the quarter. Requests will be processed in the order they are received. Requests after the 15th day of the month will be processed in the following quarter.

Co-op Finance Program Quarterly Finance Requests cut off dates:
Q1 - March 15th
Q2 - June 15th
Q3 - September 15th
Q4 - December 15th

Note: If the 15th day falls on a weekend, the cut off date will be the Friday before the 15th

Contact Information *
EAN: *
Company Name: *
Main Contact : *
Address: *		City: *
State: *	Select State AL - Alabama AK - Alaska AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DE - Delaware FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VI - Virgin Islands VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming	Zip: *
Store Phone : *		Cell Phone: *
Email: *
AW Account Manager: *	Select One ---- Anthony DeFilippis ---- David DiBattista James Sanchez Joshua Thompson Larry Maybin Shannon Saunders Tom Sinnott ---- Chuck Whitney ---- Chuck Whitney Clint Macklin Danielle Wagner Jennifer Merritt Joe Walsh Karla Ore Kyle McCune Lim Chheang Mark Wilson Nathaniel Birdsong Pete Kakoliris Steve Schnittker Thuan Duong Tim Booth Troy Keoki Walter ---- Jamie Bifulco ---- NA2 Ryan Molpus Tina Ellis ---- Orlando Uranga ---- Brenda Chavez Casey MacManus Claudia Fredrickson Daniel Liu Eric Johnson Greg Pielaat House Account Kim La Michael Adelman Michelle Medak na1 Nathan Goodspeed Noah Lahli Tim Au Vj Zakarian ---- Ryan Molpus ---- Emmanuel Arreola Kelly Reitzer-Lee ---- Tina Ellis ---- Jason Sacramento na3
Dealer Program Information: *
Budget Range: * $1000 - $1999 $2,000 - $3,499 $3,500 - $4,999 $5,000 - $7,499 $7,500 - $9,999 $10,000 - $14,999 $15,000 Plus
Carrier: * Verizon Sprint/Nextel Helio DISH Network
Approved Media Vendor: Lorex Pennysaver
Approved Non-Traditional Media Flexblade       9'       12'       14'       16' LED Light Box       11" x 17"       22" x 28" Dish EZ Up Tente
Special Media Request Print Radio TV  Other
Special Media Request Vendor Information Estimated campaign start date * Month  ----- 1 2 3 4 5 6 7 8 9 10 11 12   Day  ----- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year  --------- 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 What's the name of the media company? What's the media company's phone number? What is the Sales Representatives name? Have you advertised using this Media Vendor before? * Yes No What is the Sales Representatives email address?
Art Work to be used: * Carrier Template AW Template Own Artwork
What is your Preferred Method of Communication? * Preferred Choice Alternative Choice Email Email Store Phone Store Phone Cell Phone Cell Phone Fax Fax
I agree to the terms and conditions of the co-op fund release agreement.