Please fill out the form below to apply to become a reseller of Code products.

Please provide the following information:

RESELLER APPLICATION
Company Name:
Address 1:
Address 2:
City:
State or Province:	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MO MS MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA VT WA WV WI WY DC
Zip or Postal Code:
Telephone Number:
Fax:
Website URL:
Where or how did you learn about Code Corporation:
CONTACT INFORMATION
Name:
Title:
*Email:	(required)
BUSINESS STRUCTURE AND BACKGROUND
Date Business Established:	/ / (MM/DD/YYYY)
Organization Type:	Sole Proprietorship Partnership Corporation
Number of Employees:
Target Sales Territory:	Local Regional National International
Sales Revenue:	$0 - $100K $100K - $500K $500K - $1M $1M - $5M $5M+
Revenue Breakdown:	% of Revenue from System % of Revenue from Software % of Revenue from Components & Peripherals % of Revenue from Service & Support
Target Market(s):	Accounting Education Finance Health Care Insurance Legal Manufacturing Real Estate Sales Force Automation Transportation Wholesale Distribution Other - please enter a description:
Horizontal Markets:	Hardware Networking Internet / Intranet RDBMS Applications Software Other products you sell:
Product Focus:	Please list the top three products you sell: 1. 2. 3.
PROFESSIONAL SERVICES
If you have professional services, please answer the following questions:
What percentage of revenue comes from professional services?	%
What types of services does your organization provide?
How many people are employed in your service organization?
CORPORATE CONTACT INFORMATION
Executive Contact:
Executive Title:
Executive Email:
Financial Contact:
Financial Title:
Financial Email:
Admin/Purchasing Contact:
Admin/Purchasing Title:
Admin/Purchasing Email:
Sales/Marketing Contact:
Sales/Marketing Title:
Sales/Marketing Email:
Service/Support Contact:
Service/Support Title:
Service/Support Email:
Re-Type Security Code: