Company Information
Mailing Address*
City*
Province*
Postal Code*
Number of years in business *
Number of Employees*
Website
Contact Information
First Name*
Last Name*
Title
Job Function *
Choose one...
Administrative/Clerical
Executive Management
Finance/Accounting
Information Systems/Technical
Marketing/Sales
Merchandising/Display
Operations/Manufacturing/Assembly
Purchasing
Phone*
Ext.
Fax
E-mail*
Password*
Your Business
Annual Total Sales Revenue*
Choose one...
0 - $249,999
$250K - $499,999
$500K - $999,999
$1M - $1,999,999
$2M - $4,999,999
$5M - $9,999,999
$10M - $24,999,999
$25M+
Primary distributor name
Choose one...
Ingram Micro
Tech Data
D&H
Stampede
Activelight
Cinelight
Starin Distribution
DBL
TDL
SummitFX
Progressive
Evolution Audio Video
Your Reseller Number
Secondary distributor name
Choose one...
Ingram Micro
Tech Data
D&H
Stampede
Activelight
Cinelight
Starin Distribution
DBL
TDL
SummitFX
Progressive
Evolution Audio Video
Your Reseller Number
Please apply percentages to each of the following market segments served by your business
Staff (indicate number)
Channel*
Choose one...
Distributor
e-Tailer
Reseller
System Builder/Integrator
Retailer
Other
Your Business License
I HEREBY CERTIFY: That I hold a valid Reseller's Permit
Reseller's Permit No.*
State*
Business of selling*
A PartnerVizion Representative will contact you to obtain a copy of your Reseller Permit.
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