National / AZON AUTHORIZED EPSON RESELLER APPLICATION

EPSON RESELLER APPLICATION
Company Name
DBA (if different)
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Shipping Address

Street Address

Street Address Line 2

CityState

Zip Code
Location of other branches (List all)
Email
example@example.com
Website
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
APPLICANT CONTACT INFORMATION
Sales Management Contact
Phone Number

Area CodePhone Number
Email
example@example.com
Purchasing Contact
Phone Number

Area CodePhone Number
Email
example@example.com
Purchasing Contact
Phone Number

Area CodePhone Number
Email
example@example.com
CORPORATE PROFILE
Primary Business Description
Organization Type
Years in Business
SALES AND MARKETING INFORMATION
Target Application Market
Target Geographic Market
Related products/services currently being sold
Principle Market Served
PLEASE INDICATE PRODUCT LINE INTEREST
Comments
I have completed the Reseller Application and certify that the information provided is correct and accurate as of the date signed below. I understand that my reseller authorization must be renewed annually in-order-to maintain the Authorized Reseller privileges.
Signature of Applicant (Officer)
Printed Name and Title
Date Signed

MonthDayYear
Date
Should be Empty:

EPSON RESELLER APPLICATION