Reseller Application

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If you wish to become a reseller please fill out the form below:

Company Information

Company Name
Phone Number
Email Address
DBA
Fax Number
Website

Section 1 - Business Information

Legal Business Name
*As it appears in business license
Fed Tax ID#
Business Street Address
City
State
Zip Code
Country
Business Phone Number
SIP
FAX
Toll Free Number:
*Billing Address*
City
State
Zip Code
Country
Shipping Street Address
City
State
Zip Code
Country

Type of Business
Type of Business
Year Established
State of Incorporation
D&B Number
Number of Employees
Are you a subsidiary or Division
*Parent Company Name*
Parent Company Name
Parent Company Address
Street
City
State
Zip Code
Parent Company D&B No.
Adress (City , State & Zip Code)
Phone Number
Email
Have you ever filed for Bankruptcy
Date Filed
Status

Please provide a list of Vendors/Service Providers with whom you are doing business now

Vendor 1

Vendor 2

Vendor 3

Vendor 4

Main Distributors:

Account Number:

Distributor 1

Distributor 2

Distributor 3

Distributor 4

Please select areas of expertise:

VoIP Gateways

Wireless

Security

IP PBX over Windows

IP PBX over Linux

IP Telephony

SIP Trunking

Please select areas of interest:

VoIP Gateways

Wireless

Security

IP PBX over Windows

IP PBX over Linux

IP Telephony

SIP Trunking

Section 2 - Contact Information

*Main Contact*
Full Name
Title
Phone Number
Email

Technical *Contact*
Full Name
Title
Phone Number
Email

Commercial Contact
Full Name
Title
Phone Number
Email

Financial *Contact*
Full Name
Title
Phone Number
Email

Operations *Contact*
Full Name
Title
Phone Number
Email

Section 3 - Tax Information

If your company has tax exemption, we require that you provide us with your Tax Certificate of Exemption.
State Resale Certificate Number
( A copy of the certificate must be mailed with this form)

Section 4 - References

Bank Reference

Bank Name
Address
City
State
Zip
Country
*Account Officer Name*
Phone
Fax
Email
Account Number
Account Number

*Trade References*
Company Name 1
Address
City
State
Zip
Country
*Contact Name*
Phone
Fax
Email
Account Number
Payment Terms

*Trade References*
Company Name 2
Address
City
State
Zip
Country
*Contact Name*
Phone
Fax
Email
Account Number
Payment Terms

Section 5 - Authorization

Please list any authorized reseller agreement that you may have

Which brands do you sell?( List the ones that make 60% or more of your annual revenue)
Please specify which vertical markets you address:
I hereby certify that all the information given herein is true and correct to the best of my knowledge; and I understand that providing incorrect information on this application may result and possible delay or denial. I have read this application. Furthermore, I authorize the banks and companies given as reference herein to release XmarteK, information relevant to this application. This application is not an agreement and does not guarantee me acceptance to receive a XmarteK Reseller Agreement and in no way binds me to any obligation with XmarteK.
Name
Title
Email
Date

Telephone 1 954 385 7280 FAX 1 954 3857280
2830 Oakbrook Lane Ft Lauderdale FL, 33332 PO Box 267865 Ft Lauderdale , FL 33326
General Information: info@xmartek.com
Last modified: 01/12/10
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