CHANNEL PARTNER APPLICATION

GENERAL INFORMATION

     Firm Name: ______________________________ Tax I.D. # _____________________

     DBA Name: ____________________________, Firms E-mail _____________________

     Address: _________________________ City: _____________,  State: _______,  Zip ________

     Type of Business:      □ Corporation      □ LLC      □ Partnership      □ Proprietorship    

     Officer/Owners Name:  _____________________,  SSN#: _____________ E-mail: ___________

     Address: _____________________, City: _______________State: ________, Zip Code _______

     Date Established:  ____________,  Contact Person:  _____________ Phone # _______________

    Banking Info:  Name of Bank:  ________________________, Contact: ___________________

    Address: ______________________, City: ________________, State: _____, Zip Code: ________

   Telephone: _______________  Fax: ________________ E-mail: ___________________________

   Checking account Numbers to be used:  Routing#  ______________ Account # _______________

   Credit Card to be used:   VISA    Master Card    American Express    Discover    Other

   Card # _______________________,   Exp. Date:  ______  Name on Card: ___________________

Card Billing Address: ______________________,  City: ____________,  State: _____  Zip: ________

TRADE REFERENCES

1. Company: ___________________, Address, _________________________, City, ___________

   Contact: ____________________, Phone: __________________, Fax: ___________________

   Type of Products Purchased: ___________________________________________________

    Length of business relationship:____________  E-Mail: _________________________

2. Company: ___________________, Address, _________________________, City, ___________

   Contact: ____________________, Phone: __________________, Fax: ___________________

   Type of Products Purchased: ___________________________________________________

    Length of business relationship: __________________ E-Mail: ________________________

Applicants  Signature _____________________________

Title: ____________________,      Date: _________