HumanConcepts Partner Application

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Partner Application Form

What OrgPlus partner program are you interested in?

Software Developer
Value-added Reseller
Reseller

Contact Name

Company Name

Address

City

State/Province

Country

Zip / Postal Code

Phone

Fax

Company Personnel

Role	Contact Name	Email Address
President
Sales
Marketing
Professional Services

Please tell us about your organisation

What year was your organisation founded?
How many employees in your organisation?
What does your organisation do? (Check all that apply)
Resell Software
Provide Consulting Services
Provide Systems Integration

Which software products do you currently develop or represent?
Please indicate the product's industry focus and number of customers you have with each product.

Product	Industry	# of Customers

Do you focus on vertical markets? Which?

Does your company have a geographic focus? If yes, please indicate:

Sales and Revenues

What was your annual revenue for the most recently ended fiscal year?
What is your expected revenue from new customers in the next 12 months?

References

Please provide at least two Customer references - companies that have purchased products or hired your company to provide services:

Company name
Contact name
Contact title
Phone
Email
Description of product or service provided:

Company name
Contact name
Contact title
Phone
Email
Description of product or service provided: