Quintum Reseller Partner Program Application

If you are interested in becoming a reseller in Asia, please send us an email by clicking here.

In order for Quintum to process your application, you must complete all required fields. Thank you.

Fields marked in red are required. Company Name: Address 1: Address 2: City: State/Province: Non-US/Canada Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Zip/Postal Code: Country: United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo The Democratic Republic of the Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Islamic Republic of Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea Democratic People's Republic of Korea Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Federated States of Moldova Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands British Virgin Islands U.S. Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe Telephone:   Use Format: xxx-xxx-xxxx Fax:   Use Format: xxx-xxx-xxxx Website:   http:// Information about the person who will sign contract. First Name: Last Name: Title: E-mail Address:

State & Date of Incorporation:

What is the size of the company?

Annual Revenue ($):

Number of Employees:

How is revenue divided up among these general categories? (% of total annual sales must = 100%):

Routers	Software
LAN	Cabling
WAN	Voice Equipment
Voice/Data Integration	Access Equipment
Computer Hardware	Services
Other

How many technicians do you employ?

Corporate

In the field

What service authorizations does your company hold?

List your company's locations with the number of field personnel by branch:

Do you have more than 4 branches:   Yes No

Branch 1

Street Address	City
State/Province	Phone
# Outside Reps	# Inside Reps

Branch 2

Street Address	City
State/Province	Phone
# Outside Reps	# Inside Reps

Branch 3

Street Address	City
State/Province	Phone
# Outside Reps	# Inside Reps

Branch 4

Street Address	City
State/Province	Phone
# Outside Reps	# Inside Reps

What makes your business successful?

What territories does your business cover? Please indicate the approximate % amount of total annual sales.

North America:

Northeast    % of annual sales	Mid-Atlantic    % of annual sales	Southeast    % of annual sales
Northwest    % of annual sales	Midwest    % of annual sales	West Coast    % of annual sales
Southwest    % of annual sales	Central    % of annual sales	National    % of annual sales
Canada    % of annual sales in Canada

Latin / South America (please check countries):

Antigua and Barbuda Argentina Aruba Bahamas   Barbados Belize Bermuda Bolivia   Brazil British Virgin Islands Cayman Islands Chile   Colombia Costa Rica Dominican Republic Ecuador   El Salvador Falkland Islands (Malvinas) French Guiana Grenada   Guatemala Guyana Haiti Honduras   Jamaica Martinique Mexico Netherlands Antilles   Nicaragua Panama Paraguay Peru   Puerto Rico Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines   Suriname Trinidad and Tobago Turks and Caicos Islands U.S. Virgin Islands   Uruguay Venezuela          % of annual sales in Latin America

Asia (please check countries):

Afghanistan American Samoa Bangladesh Bhutan   Brunei Darussalam Cambodia China Fiji   Guam Hong Kong India Indonesia   Japan Mongolia Laos Macau   Malaysia Maldives Myanmar Nepal   North Korea Pakistan Philippines Samoa   Singapore South Korea Sri Lanka Taiwan   Thailand Vietnam          % of annual sales in Asia

Europe (please check countries):

Albania Andorra Armenia Austria   Azerbaijan Belarus Belgium Bosnia and Herzegowina   Bulgaria Croatia Cyprus Czech Republic   Denmark Estonia Faroe Islands Finland   France Georgia Germany Gibraltar   Greece Greenland Holy See (Vatican City State) Hungary   Iceland Ireland Italy Latvia   Liechtenstein Lithuania Luxembourg Macedonia, The Former Yugoslav Republic of   Malta Moldova, Republic of Monaco Netherlands   Norway Poland Portugal Romania   Russian Federation San Marino Slovakia Slovenia   Spain Svalbard and Jan Mayen Sweden Switzerland   Ukraine United Kingdom Yugoslavia        % of annual sales in Europe

Middle East/Africa (please check countries):

Bahrain Iran, Islamic Republic of Iraq Israel   Jordan Kazakstan Kuwait Kyrgyzstan   Lebanon Northern Mariana Islands Oman Qatar   Saudi Arabia Syrian Arab Republic Tajikistan Turkey   Turkmenistan United Arab Emirates Uzbekistan Yemen    % of annual sales in Middle East

Africa    % of annual sales in Africa

Africa (please check countries):

Who are your target customers?

What is your total number of customers?

What percentage of your customers are (% must equal 100%):

Large Enterprises (>10,000 employees):

Medium Enterprises (1,000 - 9,999 employees):

Small Enterprises (<1,000 employees):

ILECs:

CLECs:

ISPs:

Long Distance Carriers:

Other:

Who are your top 3 vendors?

Vendor 1:

Vendor 2:

Vendor 3:

List other convergent networking vendors whose line(s) you currently carry:

What markets does your company target? (check all that apply):   Banking/Finance Manufacturing   Business/Office Automation Real Estate   Construction/Architecture Recreation/Hospitality   Engineering/Scientific Retail   Transportation Education   Government/Military Utilities   Aerospace Wholesale/Distribution   Health/Medical/Dental/Pharmacy Legal   Other None

What are the titles or levels of your customers? (check all that apply):   Executive Management (Chairman, CEO, President, Principal, Partner, etc.)   Corporate Management (Financial, Administration, Operations, Purchasing)   Technical Management   Consulting Management   Marketing/Sales Management   Marketing/Sales Staff   Technical Staff   Other

What percentage of your customers purchase at the following Levels?

Over $5 million

$1 million to $5 million

$500,000 to $1 million

$100,000 to $500,000

Under $100,000

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