Reseller Application

Please fill out our on-line form. Or you may print it, fill it out and mail or fax it to us at the following address:

Mail: GTEK, Inc., P.O. Box 2310, Bay St. Louis, MS 39521-2310

Fax: (601) 467-0935

Please fill out all applicable fields. Use the TAB key to move to the next field.

A. Company Information

Company
Address
City
State/Province
Zip/Postal Code
Voice Phone
Fax Phone
E-Mail
Web Site
Sales Contact

B. Please list three companies whose products you resell.

Company #1
Address
City
State/Province
Zip/Postal Code
Phone
Fax
Contact

Company #2
Address
City
State/Province
Zip/Postal Code
Phone
Fax
Contact

Company #3
Address
City
State/Province
Zip/Postal Code
Phone
Fax
Contact

C. List two bank references.

Reference 1:

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

Reference 2:

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

D. My target sales markets are: (check all that apply)

Retail	CAD / CAM	Desktop Publishing
Wholesale Distribution	Real Estate	Education
Banking / Financial	Legal	Medical / Dental
Accounting	Government	Construction
Insurance	Non-Profit	Internet Connectivity
BBS Industry	Scientific/Engineering	Multimedia

E. The primary business activity of my firm is: (check only one)

System / Software Developer	Hardware / Software Developer
In-house Corporate Reseller	Value Added Dealer
Renting / Leasing Organization	Value Added Reseller
Consultants who resell	Systems House
Manufacturers who resell	Software House
Office Machine Dealer	Manufacturers Rep.
Distributor	Government Buyer

F. What GTEK Products are you interested in? (Check all that apply)

	Intelligent Serial Boards
	Non-Intelligent Serial Boards
	Development Hardware/Software

G. What is your estimated annual marketing budget? (check only one)

	$0-9,999		$100,000-499,999
	$10,000-49,000		$500,000-999,999
	$50,000-99,999		$1,000,000 +

Reseller Application

A. Company Information

B. Please list three companies whose products you resell.

C. List two bank references.

Reference 1:

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

Reference 2:

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

D. My target sales markets are: (check all that apply)

E. The primary business activity of my firm is: (check only one)

F. What GTEK Products are you interested in? (Check all that apply)

G. What is your estimated annual marketing budget? (check only one)

H. What portion of your advertising budget do you plan to dedicate to promoting GTEK products?

I. What is your estimated annual purchase of GTEK products (in U.S. Dollars)

J. Number of employees at your firm?

1 - 49 50 - 99 100 - 499 500 - 999 1000 +

Thank you very much for supplying this information.
You will be contacted by phone or e-mail within the next business day.

Reseller Application

A. Company Information

B. Please list three companies whose products you resell.

C. List two bank references.

Reference 1:

Bank Name Address City State/Province Zip/Postal Code Phone Fax

Reference 2:

Bank Name Address City State/Province Zip/Postal Code Phone Fax

D. My target sales markets are: (check all that apply)

E. The primary business activity of my firm is: (check only one)

F. What GTEK Products are you interested in? (Check all that apply)

G. What is your estimated annual marketing budget? (check only one)

H. What portion of your advertising budget do you plan to dedicate to promoting GTEK products?

I. What is your estimated annual purchase of GTEK products (in U.S. Dollars)

J. Number of employees at your firm? 1 - 49 50 - 99 100 - 499 500 - 999 1000 +

Thank you very much for supplying this information. You will be contacted by phone or e-mail within the next business day.

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

Bank Name
Address
City
State/Province
Zip/Postal Code
Phone
Fax

J. Number of employees at your firm?

1 - 49 50 - 99 100 - 499 500 - 999 1000 +

Thank you very much for supplying this information.
You will be contacted by phone or e-mail within the next business day.