Please fill up the form and we will notify you once your application is approved. All fields marked with a red asterisk (*) are required.

First Name*	:
Last Name*	:
Title*	:
Company*	:
Address*	:
	:
City*	:
State/Province*	:
Country*	:	- Select Country - Algeria Angola Antigua Argentina Armenia, Rep. Of Australia Austria Bahamas Bahrain Bangladesh Barbados Belgium Belize Benin Bermuda Botswana Brazil Brunei Bulgaria Cambodia Cameroon Canada Cayman Islands Chile China Colombia Congo Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Dominican Republic Ecuador Egypt Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Germany Ghana Greece Guam Guatamala Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Laos Lebanon Lesotho Libya Luxembourg Macau Madagascar Malawi Malaysia-East Malaysia-West Maldives Malta Martinique Mauritius Mexico Morocco Myanmar Namibia Nepal Netherland Antilles Netherlands New Caledonia New Zealand Nicaragua Nigeria North Korea Norway Oman Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Island Romania Russian Federation Saudi Arabia Seychelles Singapore Slovakia Solomon Islands South Africa South Korea Spain Sri Lanka Sudan Sweden Switzerland Syria Tahiti Taiwan Tanzania Thailand Trinidad & Tobago Tunesia Turkay Turkmenistan U.A.E. Uganda Ukraine United Kingdom Uruguay U.S.A. Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.A.) Yemen Yugoslavia Zambia Zimbabwe
E-mail*	:
Telephone*	:
Fax	:
URL	:

Organization Type*	:	Sole Proprietorship Partnership
Nature of busines*	:	Retail Storefront
Others, Please specify	:
How many months/years in business established?	:
How many branches does your company have?	:
How many resellers does your company have?	:
Previous Year Sales Revenue*	:	Up to $100,000 $100,000 -- $500,000 $500,000 -- $1000,000 $1000,000 -- $10,000,000 $10,000,00 -- $50,000,000 $50,000,000 or more
Do you assemble your own PCs, Please check if yes
Do you provide networking solution?	:	Yes      No
Number of PCs sold per month	:	less than 50 50 -- 100 100 -- 500 Over 500
Number of Employees*	:
Total Amount of Sales per year	:
Number of Technicians	: