Reseller Application Form

 

 

 

Please use the form below to apply to become a reseller. All information submitted becomes property of J&W.
Please note that only qualified applicants will be contacted.

 

Company Profile Information
(Items in
RED are required)

Seller's Permit or Reseller ID:

Company:

Address:

 

Suite #:

City:

State:

Zip:

Phone:

Fax:

Web Site URL:

Business Channel Type

Please check one

Integrator
Developer
VAR
Storefront
Brief description of your business

Product Focus (Check all that apply)

Check all that apply

Personal
Education
Server
Government
Other (please describe)
Contact Information

Name:

Title:

Email:


Business Structure and Background

Date business established:

/ /

Organization Type:

Sole Proprietorship
Partnership
Corporation

Number of Employees:

Target Sales Territory:

Local
Regional
National

Sales Revenue:

$0 - $100k
$100k - $500k
$500k - $1m
$1m - $5m
$5m - +

Revenue Breakdown:

% Revenue from System
% Revenue from Software
% Revenue from Components & Peripherals
% Revenue from Service & Support

Target Market(s)

Horizontal Markets:

Wide Area Networks
Internet / Intranet
Local Area Networks
RDBMS Applications
Other (please describe)
Other Sales Locations

City:

State:

City:

State: