1. Company Information

Corporate Name D/B/A: *
Address:
City: State/Province/County:
ZIP/Postal Code:
Country:
Phone Number: *
Fax Number:
Web site:

2. Contacts

Main Contact Name (overall owner of the relationship between Reseller and Lattice3D): *
Main Contact Email Address: *
CEO/President Name:
CEO/President Email Address:
Technical Support Manager Name:
Technical Support Manager Email Address:

3. Description of your Business

Date Established:
Additional Office Locations:
Company's prior year annual sales:
Company's projected revenue for this year:

4. Number of full-time employees

Total:
Sales Reps:
Sales Reps For Lattice3D Products:
Technical Support Staff:
Technical Support Staff for Lattice3D Products:

5. Business Model (identify major focus)

Value Added Reseller
Consultant
System Integrator
Developer
Education Center
Retail Outlet

Your company's current vertical focus (Check all that apply):

Automotive Manufacturing
Aerospace Manufacturing
Discrete Manufacturing
Medical
Other (Please specify):

Does your company offer (Check all that apply):

Training
Technical Support Contracts
Consulting
Network Services
Integration Services
Other (Please specify):

Principle value provided by your company to its customers:
Please provide a description of value-adds and services that your company offers (i.e., reseller of software, network integration):

Current Business Relationships/ Alliances/Certifications:
Please list software vendors, hardware vendors, systems integrators with whom your company has a current representative relationship including any current certifications (i.e., Microsoft Solutions Provider Partner):

Please list the geographic areas served by your company:

Who are your competitors in the markets that you plan to sell Lattice3D products?

Please tell us why you would like to become a Lattice3D Reseller (max 100 words):

Please provide one customer reference that we can contact:
Name:
Telephone:
Email Address: