CPI Reseller Application Form

Please fill out and fax or mail this order form to
Cartesian Products, Inc.
Reseller Sales
34 Hyde Ave, Suite 3
Newton, MA 02458
tel and fax: (617) 249-0185

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: ____________________________________
By signature below, I authorize Cartesian Products to charge the credit card listed above the reseller cost of all software resold by reseller and delivered by Cartesian Products, Inc. as well as any applicable annual minimum charges.

Cardholder signature: ____________________________________

Cartesian Products, Inc.