If you would like to become a CEQURUX Business Partner, please fill in the following form:

Fields in Red font are required.

Application For: Check all that apply:	Reseller Support Partner Both
Company:
Industry:	HealthcareFinancial Services UtilitiesTransportationTravel/Hospitality/Food ServiceWholesale/RetailManufacturing: Non-ComputerManufacturing: Networking/Telecom EquipmentManufacturing: Computer/SoftwarePortal/Web DestinationGovernmentEducation MilitaryAerospaceLocal Exchange CarrierCompetitive Local Exchange CarrierInterexchange/Long Distance CarrierInternet Service ProviderInternational PTTWireless/Cellular/PCSSatellite Service ProviderCable/Broadcast/TVCarrier Service ResellerComputer Network Reseller/Retailer/VARSystems Integration/ConsultingOther
Name:
Title:
department:
E-mail:
Telephone:
Fax:
Address:
City:
State/Province:
Zip/Postal Code:
Country:	US ALGERIA ANDORRA ANGUILLA ANTIGUA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA BAHAMAS BAHRAIN BELARUS BELGIUM BELIZE BERMUDA BOLIVIA BRAZIL BRUNEI BULGARIA CANADA CAYMAN CHILE CHINA PRC COLOMBIA COSTA RICA CROATIA CYPRUS CZECH REP DENMARK DOMINICA DOMINICAN REP ECUADOR EGYPT EL SALVADOR ESTONIA FIJI ETHIOPIA FAROE IS. FINLAND FRANCE FR GUIANA FR POLYNESIA GEORGIA GERMANY GHANA GIBRALTER GREECE GREENLAND GUADELOUPE GUAM GUATEMALA GUYANA HONDURAS HUNGARY ICELAND INDIA INDONESIA IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KUWAIT LATVIA LEBANON LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MALAYSIA MALTA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MOROCCO NAMIBIA NETHERLANDS ANTILLES NEWCALEDONIA NEW ZEALAND NICARAGUA N IRELAND NORWAY OMAN PAKISTAN PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL QATAR ROMANIA RUSSIA SAINT LUCIA SAN MARINO SAUDI ARABIA SINGAPORE SLOVAK REP SLOVAKIA SLOVENIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA SWEDEN SWITZERLAND TAIWAN ROC THAILAND TONGA TRINIDAD TUNISIA TURKEY UKRAINE UAE UK URUGUAY UZBEKISTAN VENEZUELA VATICAN VIETNAM YUGOSLAVIA ZAMBIA ZIMBABWE Other....
Web URL:
INFORMATION ABOUT YOUR COMPANY
Annual Revenue
Years in Business:
Number of Employees:
List Offices Worldwide:
Describe your business (50 words):
Describe your company in the following terms: Check all that apply	Value Added Reseller Vertical Application Integrator Systems Network Integrator Government Systems Integrator Corporate Reseller Alliance Partner Other:
What are your market focuses? Check all that apply	Manufacturing Education Government Financial Services Insurance Healthcare and Legal Services Advertising Agency, Public Relations Firms, Printers Real Estate Services Other:
What is the average size company to which you sell based on the number of employees?
List current product offerings and brands:
List other reseller programs/certifications you participate in:
PLEASE PROVIDE 2 REFERENCES
Company:
Contact:
E-mail:
Telephone:
Fax:
Company:
Contact:
E-mail:
Telephone:
Fax:
Comments: