New Partner Application

Multi-jurisdiction Form Partner W9 Form Reseller Credit Application Form

All applicants are required to complete and submit the Reseller Credit Application Form, regardless of whether they are applying for a line of credit.

For help and or additional questions please reach out to us at NewPartner_US@exclusive-networks.com

Company Details

*Legal Status:

*Company Name:

Company DBA (if different):

*Company Address:

*Employer Identification Number (EIN):

*Company Website:

*Business Model:VARMSPMSSP

*Number of Employees:

*Date Business Was Established:

D&B Number:

Account Information

*A/P Contact Person & Portal Admin:

*A/P Contact Person & Portal Admin Email (This email will receive an invitation to our portal once the account setup process has been completed):

*Email Address for Invoices:

*Company Phone:

*Sales Order Confirmation Email Address:

*Do you have an open quote with exclusive?:

*Quote #:

Main Company Contacts {{rep-1_index}}

*Category:

*Name:

*Title:

*Email Address:

*Phone:

*Authorized Purchaser:

Payment Method

*Applying for credit terms?:

*Requested Credit Amount:

Trade Reference #1

*Company Name:

*Phone:

*Email:

*Address:

Reference Contact:

Trade Reference #2

*Company Name:

*Phone:

*Email:

*Address:

Reference Contact:

Bank Reference

*Name of Bank:

*Account #:

*Phone:

*Address:

Contact Name:

*Estimated Monthly Purchases:

*Are you interested in purchasing via an OPEX model (Hardware- as-a-Service)?:

Upload Your Docs

*Upload Field: W-9:

Upload Field: Sales Tax Exemption Certificate:

Upload Filed: Other:

Acknowledgement

Owner/Partner/Corporate Officer Name (The signing party warrants and represents that she/he is a duly authorized signatory on behalf of the Reseller).

Your Company Name*:

Your Contact Name*:

Your Email*:

Please Sign Below

Full Name