Datacard Reseller Application Form

Dynasys Technologies inc. 800 Belleair Rd. Clearwater, Florida 33756
	1-800-867-5968

DATACARD RESELLER APPLICATION

Print out and send / FAX to Dynasys 1-727-443-4390


Contact Name:
Signature:
Business Name (DBA):
Address:
City:
State:
Zip Code:
Telephone:
Fax:
Email:

Branch Locations:

Date Business Started:
Fed ID#:
Reseller #

Type of Organization:
Corporation	Public Private State of Incorporation
Partnership
Proprietorship

Company Contacts	Name Title Phone/Fax
Marketing
Sales
Contracts
Service
Other

Company Information:
Please list the principals in your organization and their backgrounds or attach resumes:
Name:
Title:
Brief Background
Name:
Title:
Brief Background
Name:
Title:
Brief Background

Total Number of Employees:

Estimated Yearly Sales Volume (in dollars):
1) 0
2) $1 - $50,000
3) 50,001 - 100,000
4) 100,001 - 250,000
5) 250,001 - 500,000
6) 500,001 - 1,000,000
7) 1,000,001 - 2,500,000
8) 2,500,001 - 5,000,000
9) 5,000,001 - 10,000,000
10) 10,000,001 - 25,000,000
11) 25,000,001 - 50,000,000
12) 50,000,001 +

Please Check all the Industry/Verticle Markets you sell to:
Advertising/PR Firms
Agriculture/Forestry/Fishing
Architect/Engineering Firms
Banking/Financial/Securities
Business Services - other
Communications (Phone, Radio,TV,Data)
Construction
Education (K-12)
College (College/University)
Government (Federal/Military)
Government (State/Local)
Hospitality
Insurance
Manufacturing
Medical - Hospital
Medical - Office
Medical - Health Services
Non-profit Organizations
Public Utilities
Real Estate
Retail (auto,service etc.)
Transportation
Wholesale Distribution
Other