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  Dealer/Reseller Application

Complete and submit the information requested below and become part of
SimplyBrilliantPOS today!

First Name *
Last Name *
Company *
Title *
Type of Business *
Reseller Tax ID# *
Address *

City *
State *
Zipcode *
Country *
Your Website *
Office Phone *
Mobile Phone *
Email *
Number of Employees *
Number of Sales Reps *
Number of Tech Staff *
Number of Systems Sold *
Currently Selling Brand *
How did you hear about us *
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