1. Company Information

Company Name *

Address *

City *

Country *

Phone Number *

2. Contacts

Main Contact Name *

Main Contact Email Address *

3. Description of your Business

Date Established *

Company's prior year annual sales *

Company's projected revenue this year *

4. Number of full-time employees

Total Employees *

Sales Reps *

Sales Reps for 6Connex Solutions *

5. Business Model(identify major focus)^*

Distributor
Value Added Reseller
Consultant/Agency
System Integrator
Developer
Education Center
Other (Please specify)

6. Your company's current vertical focus (Check all that apply)^*

Technology
Education
Government
Healthcare/Life Sciences
Financial Services/Insurance
Manufacturing
Transportation/Logistics
Professional Services
Retail/CPG
Construction
Media/Entertainment
Other (Please specify)

7. Does your company offer (Check all that apply)^*

Training
Project/Program Management
Technical Support
Consulting
Network Services
Integration Services
Other (Please specify)

8. Principle value provided by your company to its customers: ^*

Please provide a description of value-adds and services that your company offers (i.e., reseller of software, marketing strategy, event planning consultations):

9. Please list the geographic areas served by your company: ^*

10. Please tell us why you would like to become a 6connex Reseller (max 100 words): ^*

11. Please provide one customer reference that we can contact:^*

Name *

Telephone *

Email Address *