Authorized Reseller Application Form

Please complete this form and it will immediately be submitted to Canon USA

*Required Fields
CONTACT INFORMATION
*Company
*First Name
*Last Name
*Address
*City
*State	Select a State N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Ontario Quebec Nova Scotia New Brunswick Manitoba British Columbia Prince Edward Island Saskatchewan Alberta Newfoundland and Labrador Armed Forces - AE Armed Forces - AP Armed Forces - AA
*Postal Code
*Phone Number	()
Mobile Phone	()
Fax Number	()
*Email Address
Web Site Address
BUSINESS INFORMATION
Sales Manager
E-Mail Address
Service Manager
E-Mail Address_
Mailing Contact
*Lead Contact
*Total Number Of Employees
*Number Of Inside Sales Employees
*Number Of System Engineers
*Number Of Service Employees
*Number Of Other Employees
*Do you perform service?	Yes No
If yes, what products do you perform service on?
*Do you have additional locations/branches?	Yes No
If so, how many and where are they located?
*Years in Business
*Annual Sales: $
*Do you sell your products through a catalog or over the web?	Yes No
If yes, what percentage of your business is catalog or web based?
*What territory/geography do you cover? (Please explain)
*Do you specialize in any particular vertical markets or industries? (Explain)
*What percentage of your business is hardware based?
*With what distributor do you currently have a relationship?	Carolina Wholesale Ingram Tech-Data Others
If you use other distributors, please list:
*What products do you currently sell?
*What Brand(s)?