Reseller Application
Company Information
Legal Company Name
*
DBA
*
Name of Person Filling Out This Form
*
Position/ Title
*
Email
*
example@example.com
Phone Number
*
Please enter best phone number to contact you.
Format: (000) 000-0000.
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Information
Date Established
*
Number of Employees
*
Annual Sales Volume
*
State Resale Certificate Number
*
Provide copy of the Certificate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Business Type (Select all that applies)
*
Sole Proprietorship
Partnership
Corporation
LLC
Sole Proprietorship:
*
Name of Owner
SSN
Partnership, Name of Partner and Percentage of Company held:
*
Owner #1, % owned
Owner #2, % owned
Corporation:
*
State of Incorporation
Tax ID #
List Corporate Officers
President
*
VP Finance/ Comptroller
*
D & B Number
*
*
Publicly held
Private
Years in Dental Digital business
*
Business Type
*
Local
Regional
National
Number of Branches
*
Number of Equipment Reps
*
Previous experience in digital imaging
*
Sensors
Cameras
Software
Pan/ Ceph
CBCT
Handheld X-ray
3D Scanner
Shade Analyzer
What products are you interested in?
*
Sensors
Cameras
Software
Pan/ Ceph
CBCT
Handheld X-ray
3D Scanner
Shade Analyzer
Will your company handle its own support of products?
*
Please Select
Yes
No
TRADE REFERENCES
Please list two references
1. Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Account #
*
2. Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Account #
*
By typing my name below, I hereby certify that the foregoing information is true and correct to my best knowledge. Any misrepresentation may result in immediate cancellation of agreements with Denterprise International Inc.
*
This serves as your E-Signature
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: