Eurocom

NEW DEALER APPLICATION FORM Print this page	Eurocom Corporation 148 Colonnade Road, Ottawa, ON K2E 7R4 Tel: 613-224-6122 ext. 302 Fax: 613-224-2511 E-mail: sales@eurocom.com www.eurocom.com
If you would like to become a EUROCOM Reseller, please fill out this form and click on the Submit button. To be able to order EUROCOM systems online, you need to be an active EUROCOM Reseller. Please contact us at sales@eurocom.com or call 1-877-EUROCOM / (613) 224-6122 ext 302.

Legal Company Name:*

Corporate Number:

Dun & Bradstreet#:

P.S.T # (Ontario):

Tax ID Number (US)
VAT ID Number (EU)

Country:*

Street Address:*

City:*

Province/State:*

Postal/Zip Code:*

Phone #:*

Fax:

Main Contact - Sales Manager or Purchaser:
First Name:*		E-mail:*
Last Name:*
Marketing Contact:
First Name:		E-mail:
Last Name:
Service & Support Contact:
First Name:		E-mail:
Last Name:
Accounts Payable Contact:
First Name:		E-mail:
Last Name:

Website Address:

Your Eurocom Sales Rep:

Business Type:*

Operating Since:*

Revenue (Last Fiscal Year):

# of Employees:*

# of salespeople:*

Do you sell Notebooks now: (What Brands)*

Notebook Sales/month in $:

Notebook sales/month in units:

Do you carry Demos:*

Do you have a Demo showroom ?:*

Location size (sq.ft):*

How did you hear of Us:

Do you Advertise:

If yes, What Publications: