CPI Reseller Application Form

Reseller information

Name:	____________________________________
Title:	____________________________________
Company name:	____________________________________
Company address:	____________________________________
City:	____________________________________
State:	____________________________________
Zip/postal code:	____________________________________
Country:	____________________________________
Telephone number:	____________________________________
Fax number:	____________________________________
Email address:	____________________________________
Nature of business:	___ software distributor ___ value-added reseller ___ system integrator ___ independent contractor ___ other; please specify: ____________________________________

Payment information

Cardholder name:	____________________________________
Card number:	____________________________________
Expiration date:	____________________________________

Cardholder signature:

____________________________________

Cartesian Products, Inc.
cpi@cartesianinc.com