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DISTRIBUTOR EVALUATION

Reseller Opportunity
Distributors, Reseller & VARs - Resell our Products

Please print this form, provide all information requested, and return by fax or regular mail.
Fax to: 423-775-0611. Mail to: Interactive Products Corporation, 148 Bluff Road, Dayton, TN 37321.

IMPORTANT!
You must provide contact names and fax numbers for your references.

Any application received without contact names and fax numbers will not be processed.
You must also complete the
BANK REFERENCE.



COMPANY PROFILE
Company Name:
_________________________________________________________
Doing Business As:
_________________________________________________________
Address:
_________________________________________________________
  _________________________________________________________
  _________________________________________________________
City:
_________________________________________________________
State:
________________________
Postal Code:
___________________
Country:
________________________
Contact:
________________________
Phone:
___________________
E-mail:
________________________
Website:
___________________
Year Established:
________________________
   
Business Type:
________________________    
# of Branches:
________________________    
# of Salespeople:
________________________    

OWNER INFORMATION
Name:
_________________________________________________________
Home Address:
_________________________________________________________
  _________________________________________________________
City:
_________________________________________________________
State:
________________________ Postal Code: ___________________
Country:
________________________
Social Security No:
________________________ Home Phone: ___________________
Credit Requested:
$____________    
Products of interest:
_________________________________________________________

CREDIT REFERENCES
Reference 1:
_________________________________________________________
Address:
_________________________________________________________
  _________________________________________________________
Contact:
________________________
Phone:
___________________
Credit Limit:
________________________
Fax:
___________________

Reference 2:
_________________________________________________________
Address:
_________________________________________________________
  _________________________________________________________
Contact:
________________________
Phone:
___________________
Credit Limit:
________________________
Fax:
___________________

Reference 3:
_________________________________________________________
Address:
_________________________________________________________
  _________________________________________________________
Contact:
________________________
Phone:
___________________
Credit Limit:
________________________
Fax:
___________________

Accts. Payable Contact:

________________________

Phone:

___________________

PROPRIETOR GUARANTEE
By signing this Application, I acknowledge that I have personally guaranteed the debts and obligations of my business and agree that I am personally obligated to perform all of the terms of, and make all payments to Interactive Products Corp. required by the agreement of which this Application is a part. I also authorize the listed credit references to release any information regarding my credit history.
Authorized Signature:
________________________
Date:
___________________
How did you find us? _________________________________________________
Interactive Products Corporation
148 Bluff Road, Dayton, TN 37321
Toll Free: 888-552-7867 Fax: 423-775-0611
© 1996-2011 Interactive Products Corporation. All Rights Reserved.
All brand names and product names used on these web pages are
trademarks or trade names of their respective holders.
For further information contact
ipc@laptraveler.com.