Reseller Application Form

Company Details
  1. Type of Business (Where applicable) *
    • Public Company
    • Partnership
    • Proprietary Company
    • Sole Trader
    • Other
      Please specify
    • State Postcode
  5. Same as Trading Address
    • State Postcode
  6. ( )
  7. ( )

  8. Please ensure that your email is correct as we will your sign in details to this email address

  10. Commencement of Business:
  11. Annual Turnover *
    • Less than $100,000
    • $100,000-$500,000
    • More than $500,000
  12. Employees: *
  13. Targeted Markets *
    • Top 500
    • Government
    • Medium Business
    • Small Business
    • End User
Proprietors or Directors Details *
  1. First Director / Proprietor
  2. Second Director / Proprietor
Other Details
  3. Trade References: *
    1. Company 1
    2. Company 2
Where did you hear about Impact Systems Technology ?
Terms and Conditions *
  1. * Please review our Terms and Conditons
    • * Yes, I agree with the Terms and Conditions
  4. If you spoke to a sales representative, please enter their name here