Sponsorship FAN Profile for PSMA CONNECT/VHA

PMSA CONNECT
E-mail completed form to ross.deuel@att.com - Version September 2009

Request Information
Date Submitted (DD-MM-YY Format) * 09-14-09
Submitter Name * Ross Deuel r
E-mail * rd0233@att.com
Phone * 972-977-0248
Preferred Method of Communication * E-Mail
Comments to the Profile Team (Optional)

Type of Request to Profile Team * NEW Contract - New FAN

FAN Type* GSM Only
GSM FAN Assigned by NBO:
Contract Type * CCDA

Membership Information
VHA or Provista Member? PSMA CONNECT/VHA
D&B Number (Optional)
Federal Tax ID *
Foundation Account Information Required Information Missing
BCID for at&t
Customer Designation ( 6 characters )
Financial Liability Type * Sponsorship
Service Type * Sponsorship
Service Provisioning * AWS/Partner/Affiliate Only
Company Domain Name(s) (i.e. acmeco.com) Required Information Missing
Company E-mail Domain Name(s) *
An IRU Automation (Premier) profile will be
created for this customer to automate
verification of employment utilizing the e-mail
domain(s). Failure to provide all applicable e-
mail domains will result in manual employment
verification by a Care or Activation
Representative and could also result in reduced
custom offer application and discounts.
MAC and Discount Information
Distribution Level and Method * End User Credit
Are service discounts based on attainment? * No
Member Information
Business Address * Required Information Missing
Business Name
Street
City, State ZIP
Country
Member Contact Information
(Day to Day HR Manager/Coordinator) Required Information Missing
Contact Name
Address
City, State ZIP
E-mail
Phone Number
FAX
Authorized Sponsorship Coordinator Same as Day to Day Contact
Same As Day to Day Contact x

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Company Decision Maker (Contract Signer) Same as Day to Day Contact
Same As Day to Day Contact x

Initial Premier User Same as Day to Day Contact

Same As Day to Day Contact x

Profile Information
Equipment Payment Options * Required Information Missing
Credit Card
Wireless Airtime Invoice
Airtime Payment Options * Required Information Missing
Credit Card
Wireless Airtime Invoice
Miscellaneous
Shipping Carrier * FedEx

Global Instructions

Offering (Plan) Discount PERCENTAGE only * 24%

Equipment Discount PERCENTAGE only * 45%
Accessory Discount PERCENTAGE 0%
Additional Information
Waive Activation / Waive Start of Service? * No

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