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Microcel Dealer Application Form

Title:
First Name: *
Last Name: *
Daytime Phone: * -- ext.
e.g. 555-111-5555 ext. 6789
Fax Number: -- e.g. 555-111-5555
Email Address: *
Select a User Name and Password
User Name and Password is NOT case sensitive and must be at least 6 to 20 characters long.

User Name: *
Password: *
Confirm Password: *
Password Hint:
Your password hint should remind you of what your password is.
Company Name: *
Address / Street: *
City: *
Province: *
Country: *
Postal Code: * e.g. A5A8K8
Carrier Affiliation:*
Website:

Download PST exempt form  (Adobe PDF)
(This must be signed and faxed to Microcel
905-853-4363 or Toll Free Fax 800-753-6646)

PST# (Ontario Dealers only)

If you are a registered Microcel dealer please enter your assigned codes below.

Microcel Ship to Code:  

Microcel Bill to Code:   

Requested Method of Payment

Credit Card -- Download Business Agreement **
On Account -- Download Credit Application **

NOTE: Credit Application or Business Agreement MUST be completed and faxed in before application is approved!
Yes, I would like to be notified by email of new products and promotions



(** Requires Adobe Reader)


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