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ABOUT YOUR COMPANY
Company name*
Company website*
Type of business
Number of employees
Reseller category
Year established
Yearly sales volume
BILLING ADDRESS
Company
Address 1
Address 2
City
State Province Region
Zip/Postal code
Country
SHIPPING ADDRESS
Company
Address 1
Address 2
City
State Province Region
Zip/Postal code
Country
MARKETING INFORMATION
Territory
Number of offices
Primary market
Primary customer
How you heard of us?
ABOUT YOU
Your name*
Your title
Telephone*
Fax
E-mail*
Comments or questions

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.