CB Channel Partner Leads

Company*

Street*

City*

State/Province*

Zip*

Phone* (e.g. +1NPANXXxxxx format)Phone* (e.g. +1NPANXXxxxx)

Industry*

Customer First Name*

Customer Last Name*

Customer Email* (E.G. NAME@EMAIL.COM FORMAT):

Customer Email* (E.G. NAME@EMAIL.COM FORMAT)

Customer Title

Number of Locations

Employees

Product(s) of Interest*

Master Agent*

Subagent*

Agent Name*

Agent Phone*

Agent Email*

EXISTING CUSTOMERS*
Cox ICOMS Account # (Located in the OPTIX Billing ID/CABS field associated with the Bundle Service Promotion - MUST be format 000-0000000-00 format, enter 000-0000000-00 if unknown)

NEW PROSPECTS*
Cox OPTIX Account ID # (Enter OPTIX Account ID # associated with new - MUST be format 0000000 format, enter 0000000 if unknown)

Important: The Cox ICOMS Account # or the Cox OPTIX Account ID # is required for processing the customer's MRC Promotion Code associated with the Bundled Service Promotion.

Customer Primary Need*