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Company Information

Legal Company Name *

Principle/Owner First Name

Principle/Owner Last Name

Company DBA

Business Description

Company Address *

Company City *

Company Zip Code *

Company Phone *

Email *

Company Website Address

Number of Years in Business

Company's State of Formation

Company Date of Formation

Company Federal Employer Identification Number

Retail Energy Background

# Agents Selling in Company

# Years of Experience Selling Electricity Services

# Years of Experience Selling Natural Gas Services

Professional Affiliations

Energy Market Experience

Comments

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