Applicant’s Business Information		
*Company Name:  	Contact:  	
*Primary Address : 	
*City:  	State: 	*Zip:  	
*Primary Phone:  	*Other Phone:  	
*Fax:  	*Email:  	
*Type of Entity: 	*Year Established: 	
*Gross Sales:  	* Number of Employees:  	Number of Locations: 	
Contact Information		
Department	Name	Phone	Email	
Accounts Payable				
Sales				
Administration				
Capabilities		
Phone Systems    	Install:            	Support:      	Sell:             	
LAN/WAN	Install:            	Support:      	Sell:             	
Networking Gear:	Install:            	Support:      	Sell:             	
Primary Phone System Brands Supported:  	
Primary Networking Products Brands Supported:  	
The Agreement		
I have read the IPitomy Dealer Agreement and hereby agree to abide by  the terms and conditions of the agreement.  I understand that IPitomy Communications, LLC. may modify it’s dealer program and support policies from time to time and/or cancel membership in it’s reseller programs at any time. I understand it is a requirement to purchase a DEMO SYSTEM to become a dealer. I am empowered to enter into this agreement on behalf of my organization.	
IPitomy	Dealer  	
Name:	Name:  	
Title:	Title:    	
Sign:	Sign:	
Date: 	Date:  	
This form is designed to be completed then printed.  Once printed, please sign the form and fax, email or mail it to:
IPitomy Communications, LLC
1940 Northgate Blvd. B1
Sarasota, FL 34234	Email: sales@ipitomy.com
Fax: (941)306-2220
Phone: (941)306-2200