Reseller Application Form Please provide the following contact information
Customer Number	Only if you have one
Title	- Please Select - Mr. Mrs. Ms. Miss
Contact
Business Name
Street Address
Suburb/Town/City
State/Province
Zip/Post Code
Country	AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOWINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA (local name: Hrvatska) CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC EAST TIMOR ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRANCE, METROPOLITAN FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA Gaza Strip HAITI HEARD AND MC DONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN (ISLAMIC REPUBLIC OF) IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEUTRAL ZONE NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT KITTS AND NEVIS SAINT LUCIA SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA (Slovak Republic) SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA ST. HELENA ST. PIERRE AND MIQUELON SUDAN SURINAME SVALBARD AND JAN MAYEN ISLANDS SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS (BRITISH) VIRGIN ISLANDS (U.S.) WALLIS AND FUTUNA ISLANDS WESTERN SAHARA YEMEN YUGOSLAVIA ZAIRE ZAMBIA ZIMBABWE
Work Phone
Home Phone
FAX
E-Mail
Web Site

Please provide the following information about your type of Business
Primary Activity	- Select - Sign Supplies Wide Format Printer Supplies Sign & Wide Format Printer Supplies Sreen Print Supplies Computer & Related Supplies Software Only Supplies Other - Industry Related Supplies
Do you sell Sign/Print Software?	Yes  No  Used to
If Yes what Brands?
Do you sell Sign/Print Hardware?	Yes  No  Used to
If Yes what Makes/Models? e.g. Roland Plotters and Inkjets
How do you sell Your Products? Please check all methods used	Store Front Traveling Sales Reps Telemarketing Direct Mail Yellow Pages Magazine Advertising Trade Shows Web Site (On-line Shopping/Promotion) Direct E-Mail Other
If Other please list
How do you rank your Technical Support?	N/A Average Good Exc AAA
Any software accreditations? if so please list

Please provide the following information about your Business
How many locations	- Select - 1 2 3 4 5 6+
How many employees (total)	- Select - 1-3 4-9 10-24 25-49 50-99 100+
How many years in business	- Select - 1 2 3 4 5 6+
Do you sell  Local, Interstate or Nationally?	Local  Local & Interstate  Nationally
If Local & Interstate which States/Provinces? please list
Trade Reference 1.
Business Name
Contact Name
Work Phone
FAX
E-Mail
Web Site (if no Web Site - Address)
Trade Reference 2.
Business Name
Contact Name
Work Phone
FAX
E-Mail
Web Site (if no Web Site - Address)
Trade Reference 3.
Business Name
Contact Name
Work Phone
FAX
E-Mail
Web Site (if no Web Site - Address)
Do you have any comments or information you wish to provide?