Samsung Reseller Request

Name:

Company:

Address:

City:

State:

ZIP:

Email:

Phone:

xxx-xxx-xxxx

Fax:

What is prompting your interest?

	New Business
	Samsung Website
	Letter
	Word of Mouth
	Other:

What is the time frame?

	Immediate Need
	30 to 90 Days
	3 to 6 Months
	6 Months to a Year
	No established timeframe

Are you a current Samsung dealer or have you purchased Samsung equipment as a dealer?

	Yes
	No
	I'm not sure

Do you currently have certified technicians on staff?

	Yes
	No
	I'm not sure

Are you interested in making residual income through extended programs that inTouch Communications offers? Please check all areas you would have an interest in further information.

	Data & Internet Service
	Local & Long Distance Service

Please enter any additional comments or notes you might have:

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