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Qreseller Membership Registration

Thank you for your interest in the BenQ Qreseller Program. Please read all the program rules before completing the application. Once you have submitted this application you will be activated to get you started as BenQ's reseller member and enjoying all the benefits. Please note: each field marked by an asterisk ( * ) must be completed in order for us to process your application.
*	Required field
	Company Info
*	Company Name:
*	Year Established:
*	Number of Employees:
*	Primary Business:	Store Front/Retail Online/Catalog VAR Home Office
	URL:	http:// https://       Example: www.BenQ.ca
	Primary Location
*	Address:
*	City:
*	Country:	Canada
*	Province:
*	Postal Code:
*	What is the function of this location:
		Corporate Offices Storefront
	Primary Contact
*	First Name:
*	Last Name:
	Title:
	Month of Birth:	January February March April May June July August September October November December
	Phone
*	Phone:	-
	Phone Ext.:
	Fax:	-
*	E-mail:
*	E-mail - Verify:
*	Password:
*	Password - Verify:
	Annual Sales Revenue
*	Annual Total Peripheral Sales Revenue:
		$0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil
	Annual Total Sales Revenue Per Product Line:
	Display $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Storage $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Scanners / Imaging $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Plasma $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Digital Cameras $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Keyboards / Mice $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil Projectors $0 $1-$100k $101k-$250k $251k-$500k $501k-$1mil
	How Did You Hear of the BenQ Reseller Program?
		Direct Mail Internet E-mail Friend Trade Show
	Publications:
	Misc Info
*	What customers do you primarily serve?
		EndUsers Small/Medium Business Large Corporate Education Government
	What is your secondary customer source?
		Education Government Home Users Large Corporate Small/Medium Business Other
	Do You Specialize in the Audio Visual / Projector Market?
		Yes No
	Do You Want to Participate in BenQ's Lead Referral Program?
		Yes No
	Mailing List
	Yes No From time to time BenQ may send you E-mail regarding BenQ products, services and special offers. If you do not want to receive such messages, please select "NO" from the buttons above.
*	I agree to the Qreseller Program Rules & Usage Guidelines
	By clicking the submit button below you agree to the above terms and conditions of the BenQ Qreseller Program, General Rules of the BenQ Qreseller Program, Lead Referral Program Rules and Demonstration Unit Program Rules: