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* Name:

* Address:

* Phone number:

* Email:

* Confirm Email:


This company is a Sole Proprietorship Partnership Corporation (specify state)
* State of Corporation:

* Date Business Established:

Lenght of Time at this Address:
* Yrs: * Mos:

* Legal Business Name (As it appears on business license):

* Business Trade Name (DBA):

* First Principle Officer's/Owner's Name Title:

Second Principle Officer's/Owner's Name (if appliable) Title:


* Business Phone:


Business Fax:


* How many employees does your company have:

* How many employees will be communicating directly with Wicked Lasers:

Authorized Purchasing Agent(s):
* Does your company finance any of your purchases through a flooring plan? Yes No
If yes, through which financing company?

* How did you hear about Wicked Lasers?

* Do you currently own or have owned any Lasers? If Yes, which make/model(s)?

* Describe your level of Laser knowledge:
Novice Amateur Intermediate Expert

* What category best describes your company's business?
Dealer
Club
Distributor
Internet sales
Mass Merchant
Direct Marketer 		Corporate reseller
Office products store
Educational/Govt. Reseller
Manufacturer
Consumer Electronics

* On average, which of the following best describes your company's total monthly product purchases (for resale purposes) through all sources?
Less than $3,000 $3,000 - $4,999 $5,000 - $9,999
Don't know

* What were your company's total gross sales last year?
Less than $5,000 $5,000 - $19,999 $20,000 - $49,999
$50,000 - $99,999 More than $100,000 Don't know

* Who do you or your company have authorized reseller agreements with?

* Where do you plan to resell Wicked Lasers?

* Briefly describe any current "Key" marketing or sales relationship that give you or your company an advantage over your competitors:

* Briefly describe any current "Key" marketing activities that are planned for the next 6 months (including advertising, editorials, promotions, etc) that are projected to increase sales:

* Please list any comments that you might have in the space provided below:

I certify that the information that I have provided above is accurate, complete and represents a concise and correct description of my company and its dealings. I understand that this information will be used by Wicked Lasers to determine eligibility for inclusion in their "Authorized Reseller" program. I also understand that Wicked Lasers will keep the information that is provided within this document confidential and will not redistribute this information to any third party.
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