Pentax Imaging - Partner Resource Site

Welcome to www.pentaxtech.com, featuring PENTAX Mobility Products, Security Products, Laser Printer & OEM Sales

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North American VAR/Reseller Application and Web Site Registration

Your submission of this application indicates your willingness to deal with Pentax Imaging Company as a member of our Partner Program.

You must complete and submit the 3 parts listed.

Application (online below)
Web site Registration (online below)
Reseller Agreement (must receive by fax or mail because of signature)

The first 2 parts follow below in online format. It will take you about 10 minutes to complete this portion of the application.

After you fill out this form, click on the "Submit Form" button below, then the 3rd part "Reseller Agreement" (that we must receive signed by fax or mail) will display for you to print and/or save on your computer, along with the application data you enter below. Because of the required signature, please review and sign the agreement portion, then fax/mail it to Pentax Imaging.

Upon approval of all three documents by Pentax Imaging Company, you will be notified of your acceptance as an authorized Pentax Imaging Reseller. A product specialist will contact you.

Additionally, we will need a copy of your reseller license via fax, mail, or attached digital copy in e-mail. You may also be asked to provide other business materials and forms of identification.

Your Location >	USA East of Mississippi River	USA West of Mississippi River, Hawaii, Alaska	Canada, Mexico, Australia, New Zealand
Send Signed Reseller Agreement To >	Eric Zaeske, Account Executive Direct: 303-460-1605 Toll Free: 1-800-543-6144, Ext. 1605 Fax: 303-728-0175 eric.zaeske@brother.com	Gary Reichle, Account Executive Direct: 303-460-1613 Toll Free: 1-800-543-6144, Ext. 1613 Fax: 303-728-0133 gary.reichle@brother.com	Peter D'Carlo , General Manager Direct: 303-728-0288 Toll Free: 1-800-543-6144, Ext. 1288 Fax: 303-728-0231 peter.dcarlo@brother.com

Or mail completed/signed agreement to the attention of the appropriate Pentax representative at:
PENTAX Imaging Company, 600 12th Street, Suite 300, Golden, CO 80401.

Application (Part 1)

* Indicates Required Fields

Name

Title

Organization

Address 1

Address 2

City

State/Province

Postal Code

Product of Interest:
PocketJet Printers, PocketJet Paper, DSmobile Scanners, Other

Company:

Company Legal Name

d/b/a

Company Address

City

State/Province

Postal Code

Main Phone

Fax

Web Address

State Sales Tax License No.

Federal Tax ID No.

D&B No.

Key Company Contacts: (INDICATE WHICH PARTIES CAN ORDER PRODUCT)

President/Owner

Title

Phone

E-mail

Sales

Title

Phone

E-mail

Technical

Title

Phone

E-mail

Accounting

Title

Phone

E-mail

Purchasing

Title

Phone

E-mail

Person Completing This Form

Title

Phone

E-mail

Describe contact information of other locations/branches to be included in the program below:

How did you hear about us? (please check all that apply and list details below)

Direct Mail Web Ad Trade Show E-mail Ad Other

Details

Company Profile:

I will e-mail a corporate logo image file and 50-word description of my company for inclusion on the pentaxtech.com web site. E-mail it to peter.dcarlo@brother.com.

Type of Business:

1. We Are:

Publicly Held

Privately Held

2. We have been in business since:

3. # of years selling computers, peripherals, etc.:

4. Annual company revenues (approx.): $

5. Total number of employees:

Sales:

6. Total # of Sales employees:

7. Please list any additional Sales or Service office locations:

8. What does your firm specialize in selling? What vertical market(s) do you focus upon?

9. Please describe your company's geographical sales and service territory:

10. How will your company provide sales support in selling Pentax products?

A.	All salespeople & technical support personnel will be trained to support the product(s).

B.	Only certain salespeople will be supporting the product(s).

These salespeople will be chosen based upon:
Existing Product Line Regional Territory

Other

If selecting option B above, please list the sales reps and locations separately:

11. Are you affiliated with any other manufacturer's Authorized Reseller Programs?

Yes No

If yes, please list your major affiliations here:

Support:

12. Total # of Technical employees:

13. Please list any technical certifications held by staff (e.g., Microsoft, CNE, etc.)

14. We provide (check all that apply):

On-site service Telephone service Warranty Work

Anything else we should know about your technical expertise or service philosophy?

Marketing:

15. Please describe how you market to your customers, and include examples if possible:

Vendor Support:

16. What support can Pentax Imaging provide to you that will make the most difference to you?

Technical Support Sales Support Marketing Support Web Support

Explain

If you are applying for a Line of Credit, please complete the following Financial section.
If you intend to transact business solely through credit card, bank transfer or COD, please skip this section.

Financial:

I will e-mail, fax, or mail a copy of my Reseller License (required for approval)

17. We are a: Corporation Partnership Proprietorship

18. Names of Officers, Partners or Proprietor:

Name

Title

Name

Title

BANK REFERENCES:

Bank Name

Contact Name

Bank Phone

Bank Fax

Bank Address

Checking Acct. #

Loan Acct. #

Bank Name

Contact Name

Bank Phone

Bank Fax

Bank Address

Checking Acct. #

Loan Acct. #

ACCOUNT REFERENCES:

PLEASE NOTE: Fax numbers are required for processing credit approval.

Organization

Contact Name

Phone

Fax

Address

City/ST/Zip

E-mail

Organization

Contact Name

Phone

Fax

Address

City/ST/Zip

E-mail

Organization

Contact Name

Phone

Fax

Address

City/ST/Zip

E-mail

Organization

Contact Name

Phone

Fax

Address

City/ST/Zip

E-mail

19. Were you ever involved in a bankruptcy or assignment for the benefit of creditors?

Yes No

If yes, please provide details:

20. Please e-mail a scan of a current financial statement. Is this: Business Personal

Order Information:

Indicate desired credit limit $

Hold first order until credit approved

Send first order COD while checking credit references

Check enclosed

Signature of Applicant: (for use if this page is printed on paper)

X-------------------------------------------------------------------------

Printed Name of Applicant

Title

Date of Signature

end of financial section

Products:

21. What percentage of your business is devoted to mobility products? %

22. What percentage of your business comes from the following markets? (should total 100%)

Public Safety

Utilities/Telco

Sales Force Automation

Health Care