Evotel Affiliates – Sales Agent Form

Affilliate Name:(Required)

First Last

Affiliate Code:(Required)

Clients Name(Required)

First Last

Enter your clients full name here.

This field is hidden when viewing the form

Geocoder

Use this button when you are at your clients installation address

Clients Installation address(Required)

Confirm your clients address where the clients fibre should be installed.

Ensure marker is on your clients Rooftop (installation address)

If the marker is not on the clients rooftop please move the marker by clicking / tapping the map on the clients home.

This field is hidden when viewing the form

GPS co-ordinates(Required)

Insert your GPS co-ordinates from the map

Package and Pricing(Required)

Select your preferred speed, installation type and ISP.

Clients Cell Phone Number(Required)

Enter your primary contact number here.

Clients Alternative Phone number

Clients Email Address(Required)

Enter Email Confirm Email

Please Enter your clients e-mail address here.

Write additional notes here.

Keep me informed of Marketing offers, notifications & product updates.

I grant permission to receive updates and notifications

Name

This field is for validation purposes and should be left unchanged.