Innovative Channel Network

Hiperwall Reseller Agreement

Complete the online form and submit, or download the print copy and return as indicated.

Company Information
Company Name
Street Address 1
Street Address 2
City
State or Province
Zip or Postal Code
EIN#
URL http://www.
State or Province - Reseller ID
Primary Contact
Email
Phone
Sales Contact
Email
Phone
Technical Contact
Email
Phone
Business Classification
Business Type
Years in Business
Employees
Annual Revenue

Percentage of Revenue by Type	Hardware %
	Software %
	Services %
Industries/Markets Served	Advertising	Agriculture	Arts & Entertainment
	Automotive	Banking & Finance	Biotech/Pharmaceutical
	Construction/Architect	Consumer Electronics	Defense
	Distribution	Education	Engineering
	Entertainment	Gov’t Federal	Gov’t Local
	Gov’t State	Graphics & Imaging	High-Tech
	Information Technology	Insurance	Internet ISP/ASP
	Law Enforcement	Legal	Manufacturing
	Marketing	Medical	Military
	Mining	Non-Profit	Oil & Gas
	Professional	Publishing	Real Estate
	Research	Software	Telecom
	Transportation	VAR
Sbmitted by
Title