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Reseller Application

Contact Information
  
Salutation:
Title:  
First Name:  
Last Name:  
Direct Phone Number:
Email Address: 
Company Information
  
Company Name:  
Address (1):
Address (2):
City:
State/Province:
Postal/Zip Code:
Country:
Company Phone Number:
Website URL:
Reseller Application
Please select the type of partnership that you envision having with Justyn Tyme Solutions:  

Please indicate the reason that you have decided to apply to be a Justyn Tyme Solutions partner at this time:  
Which of the following categories best describes your Company (check all that apply)?








If Other please indicate how you would best describe your company:

  
Business Profile
What services does your Company provide (check all that apply)?



Your Company’s approximate annual revenue:

  
Total number of employees in your Company:

  
Does your Company currently sell, Justyn Tyme Solutions products,
or has it sold them in the past?


Does your Company sell Memory Modules and ?

If Yes, which ones?

  
If you have any additional information you would like to provide, please enter it here: