ALC Authorized Dealer New Account Application Form

Company Profile:

Company Name:
Contact Name:
Business Address:

City: Province:
Postal Code: Telephone:
Fax: E-mail:
Registration #: PST #:
President: Tel #: E-mail:
Controller (A/P) Tel #: E-mail:
Sales/Mktg Tel #: E-mail:

Business Structure & Background:

Date Business Established
Total # of employees
Organization Type
Sales Revenue:
Revenue Breakdown % Revenue from systems
% Revenue from components & peripherals
% Revenue from software

% Revenue from service/support

Trade Reference:

Firm Name: Contact:
Tel #: Fax #:
Firm Name: Contact:
Tel #: Fax #:
Firm Name: Contact:
Tel #: Fax #:

Bank Reference:

Bank Name: Contact:

Branch #: Transit #: Account #:
Tel #: Fax #:

I hereby certify that the information contained herein is true and correct, and grant vendor permission to verify all information.  Further I hereby authorize the bank and trade references listed in this application to release the information necessary to assist ALC Micro in establishing an account for our company.