StarDot Reseller Application

Company Name*

First Name*		Last Name*

Job Title*

Department

Email Address*

Please Retype E-mail Address*

Phone*

Toll-Free

Fax*

Web Site*

Address Line 1*

Address Line 2

City*

State or Province*

Zip or Postal Code*

Country*

Year Established?*

Number of Employees*

Federal Tax ID Number*

Reseller License or Sales Permit #*

Dun & Bradstreet Number

Which industry or industries do you sell in?*
Security	IT
Construction
Other

At which level does your company resell?*
Installer	Dealer
VAR	Integrator
Distributor	Solutions Provider
Other

What is your annual sales revenue?*

Under $500,000 $500,000 - $2,000,000 $2,000,000 - $5,000,000

$5,000,000-$25,000,000 $25,000,000 - $200,000,000 Over $200,000,000

Have you spoken with or e-mailed anyone at StarDot before?		If yes, whom?
Yes No

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