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REDFLY Reseller Application

Note:red denotes required field

Part A: Company Information
General Background
Business Name
Doing Business As (DBA)
Street Address
City:	State: 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 West Virginia Wisconsin Wyoming Zip:
Main Phone Number:	Fax Number:
Web Address (URL)
Federal Tax ID Number:	Dun & Bradstreet Number:
Key Executives	Please list your organization?s key executives and their titles
	Name Title 1. 2. 3.
Correspondence	Celio strives to communicate new product updates and information to its Dealers in a timely and efficient manner, oftentimes via email. Please indicate below the specific people within your organization and any additional contacts you wish to receive these informational updates on our wireless products and services:
Contracts:	Person responsible for signing dealer contracts and agreements on company?s behalf Name Phone Email
Sales:	Primary sales contact for wireless products within your organization Name Phone Email
Marketing:	Person responsible for marketing of wireless products to your customers Name Phone Email
Additional Contacts:	Name Phone Email
Part B: Business Profile
Type of Organization	Corporation Sole Proprietor Partnership Other
	Check if your organization has a parent company. Parent Name Street Address City: State: -- -- 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 West Virginia Wisconsin Wyoming Zip:
Number of Years in Business:	Date established:
Company Description & Target Customers:	Describe your company?s application or value-added proposition: Describe your target customer(s) in terms of industry, size, etc: Check if you presently have a selling relationship with any wireless carriers. Please list companies you currently have selling relationships with (name and website): What type of operating systems do the SmartPhones you sell currently run on?(Check all that apply) Windows Android Blackberry Symbian Palm Which wireless vertical applications do you currently sell into? (Check all that apply) Field Service Transportation Mobile CRM Public Safety Other:
Financial Info	Please complete with your company's info
	2012 Projected Last Year Annual Revenue Number of Employees Number of Wireless Smartphones Sold Do you have a retail Location? Yes No Do you have a B2B Staff? Yes No Do you sell wireless products via the Internet? Yes No
Personnel	Please list the number of employees in the following roles:
	Executive Customer Support Sales Development Tech Support Other

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This page was last updated on Tuesday, October 6th 2009 at 3:01 pm