Reseller Application Form |

Please complete and submit the following application form if you are interested in becoming a reseller of our product “Traffic Activator”.

We will review your application and notify you within two (2) business day whether your application has been approved. You will then be contacted by our Manager/ Manageress.

Fields marked with (*) are required fields for submission.

2. Part A
3. Company Information
4. Name of Company *(required)
5. Company Reg. No. *(required)
6. Date Established *(required)
7. Description of Your Business *(required)
8. Website URL
9. Number of office locations
10. Postal Address *(required)
11. Postal Code *(required)
12. Town/ City *(required)
13. State * --Please select your state-- Johor Kedah Kelantan Labuan Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Sabah Sarawak Selangor Kuala Terengganu Wilayah Persekutuan Others (required)
14. Country * --Please select your country-- Malaysia Others (required)
15. Telephone No. *(required)
16. Fax No.
17. Part B
18. Main Contact Person's Information
19. Title * --Please select your title-- Mr Mrs Ms Mdm Others (required)
20. First Name *(required)
21. Last Name *(required)
22. Position *(required)
23. Email Address *(valid email required)
24. Contact No. *(required)
25. Part C
26. Number of your full time employees
27. Total *(required)
28. Sales Reps *(required)
29. Sales Reps for Product "Traffic Activator" *(required)
30. Please list the geographic areas served by your company *(required)
31. How did you hear about us?* --Please select your answer-- Google search Yahoo search MSN search Other Search Engines Web Link Banner Ad Newspaper Introduce by friends Others (required)
32. Additional InformationPlease provide more info other than above mentioned
33. Verification
34. CC me a copy

 

The information entered on this page will not be used to send unsolicited e-mail, and will not be sold to a 3rd party. Grow IT Marketing is not responsible for the content of the message submitted.