P.O. BOX 53151 WASHINGTON, DC 20009 USA
Telephone:(202)785-8924 or 800-TECHNOW
Fax:(202)478-0690 or 888-866-4842
DEALER APPLICATION FORM
Current Business Enterprise:_____________________________
Authorized Dealerships (secured under your current operation?) ________________________________ (use addt'l sheet, if necessary)
Intended start-up date:_____________
Relationship Requested:Reseller ($1-3,000)______Agent ($3-5,000) _____ Dealer ($5-25,000)_______ {secured by inventory for display or sale}
# Staff:_____Location___________ Territory Requested_______________
Unique Market Niche Targeted:______________________________
Knowledge of Advertising/Marketing?______(y/n) Assistance Desired_____
Personal Background Specialties (Computer, Telephone, Security..)_______
___________________________________________________________
IT'S ALL ABOUT YOU:
Name:______________________________Company:______________________
Address:____________________Billing (if different)__________________
City:___________________State:________Country____________
Contact Number:________________Fax:_____________
Authorized Signature__________________________Date_______
CHECK BOXES BELOW FOR SERVICES YOU INTEND TO OFFER:
TELEPHONE: Repair ____ Move ____ Install ___ (Home___Office____)
CELLULAR: Activation____Car Move_____Debit Card____
SATELLITE PHONE: Debit Card_____Activation______
TELECOM SERVICES:Number ID_____Special Ring____Conference____ Voice Dial___Call Forward/Remote_____ISDN_____VoIP____
ALARM MONITORING: ______
INTERNET ACCESS: 24-hour Dial-up (PPP)____56k___128k (ISDN)____
PROFESSIONAL SERVICES
LOCAL AREA NETWORKING: _________DOCUMENT SCANNING: _____
CD MASTERING: _______DESKTOP/WEB PUBLISHING:______
BUSINESS SYSTEM REPAIR:________EXT. WARRANTY PLANS:______
SYSTEM REPAIR INCLUDES: CCTV, ALARM, TELEPHONE, VOICEMAIL, PAYPHONE, POS, COMPUTER NETWORKS, ACCESS CONTROL, BUILDING ENTRY, REGISTERS, FAX
LONG DISTANCE TELEPHONE SERVICE
SRVC OUTBOUND: Home____Office____Cellular____(costs vary from $.10-.15 per minute)
INBOUND: "800/888"#_______"900"# Audiotex_______
PAY TELEPHONE ALTERNATE OPERATOR SERVICE (AOS): _____
DISCOUNT DEBIT-CALLING CARDS: USA____Int'l____Net2phone____
INT'L "RINGBACK" DISCOUNT LONG-DISTANCE: _____
OFFICE USE ONLY:Please do not write below this line
Representative Assigned:______________________ Date____________
1st Contact & Date:_________________2nd Contact & Date___________
Note:_______________________________________________________
Result:______________________________________________________