:: Reseller Application Form ::

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RESELLER APPLICATION FORM

We are pleased that you are interested in becoming a reseller of ImageGrafix. To get started, simply fill out the request form and we will send you the reseller agreement and discount information.

Company Information:

Organization:*
Address:*
City:*
Country:*
Telephone:*
Fax:
E-Mail:*
Web Site:

Administrative Contact:

Name:*

Telephone:

E-Mail:*

Sales & Marketing:

Name:*

Telephone:

E-Mail:*

Billing Contact:

Name:*

Telephone:

E-Mail:*

Business Data:

Type of Business:*
Profile of clients (Industry, size, etc.):
Geographical area served:
% of revenue from software sales:
% Revenue from hardware sales:
Anticipated sales of ImageGrafix Products and Services:*

Trade References:

Firm Name & Account Number:
Address:
Contact Name:
Telephone:

Bank References:

Bank Name & Account Number:
Address:
Contact Name:
Telephone:


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