Dealers Application

VIPERCONN with XFINITY requires a National Background Check for All Dealers!!!

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APPLICANT INFORMATION

First Name

Middle Name

Last Name

Cell Phone (to receive text messages)

Date of Birth (purposed for background check)

Social Security No. (purposed for background check)

Have you ever sold Xfinity products?

If yes, select dates
From

To

Have you ever been convicted of a felony?

If yes, explain

BUSINESS

Business Name

Business Address

Business City

Business State

Zip

Business Phone

Fax No.

Business Website

Years in Business

Number of Employees

How did you reach us?

Best time to reach you?

Brief description of type of business

Disclaimer and Signature

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Viperconn may obtain a “consumer report” about you from a consumer reporting agency for authorized dealer purposes. A “consumer” report is a background screening report that may contain information regarding your criminal history, and other information about you. It may bear upon your character, general reputation, personal characteristics, and/or mode of living.

I certify that my answers are accurate and complete to the best of my knowledge. If this application leads to authorized dealer, I understand that false or misleading information in my application or interview may result in my release. I hereby acknowledge and certify that I am of legal age.

Accept Terms & Conditions

Signature

Date

Upload Valid ID

We would like to know a little bit more about you; what are your goals?

Please download the W-9 form and fill it out completely, then email it back to cv@viperconn.com

Download W-9 Form

For dealers who plan to use their tax ID number please follow the instructions below.

XFINITY requires a National Criminal Background Check to become an agent or an authorized dealer; this process is straightforward and takes about five minutes to perform. Click SentryLink Registration link, it will take you to the sign-up page. You will need to open a free account with SecureLink, to run a national criminal background check on yourself. Price is $19.95 (choose option self-checks). Once you receive the report, please share it with us through the site. Our e-mail address is cv@viperconn.com. Once the report is received, we will continue to process.