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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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