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Dealer Application

Dealer Program Application

Please complete all relevant fields below. Everyone completing this form is carefully considered, and we will aim to get back to you with a preliminary response by the end of the next business day.

Full name:

Contact number*:

Mobile number:

Email Address*:

Which Australian states do you currently (or intend to) do business in?

Are you currently reselling ADSL, ISDN, Satellite, Wireless, etc.? If so, from whom?

Residential Address:

1. Program Selection

Are you applying as a Channel Partner or Reseller?

Channel Partner

Reseller

2. Company Primary Contact

Position:

3. Company Director or Business Proprietor

Full name:

Daytime number:

Home number:

Mobile number:

Email Address:

4. Company or Business Details

Full Registered Business/Company name:

Trading name if different from Business/Company name:

Street Address:

Postal Address:

ACN or ABN:

Year Established:

Company Phone:

Facsimile:

Website Address:

What is your company head office address? (if different from above)

Do you have offices interstate? If so, where are they located?

5. Your Business Profile

Your business focus:

Applications/solutions you sell (if applying as a Channel Partner):

Your strategic business partners:

Your main competitive advantages:

Fin.Year 2003-2004:

Fin.Year 2004-2005:

Fin.Year 2005-2006:

Year 1:

Year 2:

Year 3:

Company revenue for last 3 years:

What Clear revenue would you aim to generate in years 1, 2 & 3:

Numbers of Staff:

Sales staff

Marketing staff

Technical staff

Admin staff

Total staff

Do you intend to sell overseas?

Yes

How many customers do you currently have? How many are business? How many are residential?

Do you have your own installers?

Yes

Additional Comments:

6. Banking Details

If your application is accepted the following details will be used to deposit commissions and other payments into your bank account.

Name of Bank/Credit Union:

Bank Account Name:

BSB Number:

Bank Account Number:

8. Program Terms

Company Name:

Please provide three trading references we are permitted to call:

Contact Person:

Phone Number:

7. Trading References

If accepted you will be given a Dealer contract for review and sigining, but meanwhile please acknowledge the following key terms of our Dealer program; As a Dealer, you will bill your customers and Clear Nertworks will bill you. Thus you retain the business relations with the end user; You agree to a possible joint press release to announce our partnership; You must provide first level support to handle all your customers' questions; If approved, your contract duration will be for an initial 12 months; This is an application form, NOT a credit application.

After submitting these details, we will send you an email to acknowledge we have received your application. We will aim to get back to you in the next business day if we are lacking any important details.