Reseller Application

* First Name
* Last Name
  Title
* Company Name
* Address
* City
  State/Province
* Zip/Postal Code
* Country - Select Your Country - Afghanistan Akrotiri and Dhekelia Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Bermuda Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Cayman Islands Chad Chile China China, Republic of (Taiwan) Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Cook Islands Congo, Democratic Republic of Congo, Republic of Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Island Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Kosovo Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Midway Atoll Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian territories Palmyra Atoll Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion (overseas department of France) Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Virgin Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
* Direct Phone
  Cell Phone
  Fax
* Direct Email

What is your WWW address?

Approximately how many hits do you get on your web site per week? - Select - less than 1,000 1,000 to 5,000 5,000 or more

President/Owner's Name:

Business Form: Sole Proprietor   Partnership   Corporation

What year was the company founded?

What is your primary business? POS sales & support
Salon products & services
Education products & services
Technical consulting services
Business consulting services
Computer retailing
Computer wholesaling
Equipment leasing
Financial & card processing
E-commerce
Import/Export
Other:

Last year's revenues: - Select - under $500,000 $500,000 to $2 Million $2 Million to $5 million $5 million to $20 million More than $20 million

From which market segment does the majority of your revenue come?
Tell us about your business:
What geographic regions do you serve?

Number of employees:
Number of sales:
How many sales offices do you have?
Number of technical personnel:
Number of administrative personnel:
Market territory:
Market applications:

List of main products currently carried:
Product Name	Manufacturer	Since (year)

Remarks:

How did you hear about us? Web Search Engine       - Select - Yahoo! Google Alta Vista MSN Excite Lycos Infoseek Webcrawler HotBot Open Text AOL NetFind Other
Surfing the Net
Web Banner
Magazine
Print ad
Brochure
Trade Show
Word of mouth
School
Other

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