Reseller sign up form   ABOUT YOUR COMPANY       Company name       Pres/Owner/Partner Type of business Corporation Partnership Sole Proprietorship       Number of employees       Year established Reseller category Computer store VAR Consultant Catalog house OEM Other       Sales volume (current year)       Types of products sold Purchase orders required? Yes No       Persons authorized to purchase COMPANY BILLING ADDRESS       Billing Address       City       State       Zip       Country COMPANY SHIPPING ADDRESS       Shipping Address       City       State       Zip       Country MARKETING INFORMATION       Geographic area served Do you sell to dealers? Yes No If yes, select percentage 0% 10% 20% 30% 40% 50% 60% 70% 90% 100% Do you sell to end-users? Yes No If yes, select percentage 0% 10% 20% 30% 40% 50% 60% 70% 90% 100% Do you sell to specific vertical markets? Yes No Do you have an advertising program? Yes No       If so, what is your ad budget?       Other manufacturers' KVM switches       Brand and models       Rose products sales volume anticipated next 12 months       Number of technical support staff Do you have repair facilities? Yes No Do you have other locations? Yes No If yes, list other location(s) personnel, address, phone and fax ABOUT YOU       Your name       Your title       Name of Rose contact Where did you hear about Rose Electronics? Referral Trade Show Magazine Ad Magazine Article Web site Other       If other, specify where HOW CAN WE REACH YOU?       Telephone       Fax       E-mail ANY COMMENTS OR QUESTIONS? Comments or questions   When finished, click on SUBMIT button below

This form is an application, not an approval of Reseller status. Rose Electronics reserves the right to refuse Reseller status to any companies or individuals that do not meet minimum Reseller qualifications.