FastNeuron Inc. BackupChain Reseller Channel Partner Program Application You may complete the form below and email or mail it to FastNeuron Inc. be considered for Certified Reseller Channel Partner status. A valid email address is required so that program information can be sent to you for consideration. The completed application should be sent to the Channel Partners Program Office. It may be emailed, faxed or sent by postal mail. FastNeuron Inc. Channel Programs Office 6 Waelchli Ave #24103 Baltimore, MD 21227 USA email: sales@backupchain.com ====================================== Company Information ====================================== Company Name: Contact Name: Contact Title: Contact Email Address: Company Address: City / Locality: State / Province: Zip / Postal Code: Country: Phone: Fax: Company Web Site: ====================================== Business Details ====================================== Year Founded: Total Number of Employees: Business Type: ____Corporation ____Partnership ____Sole Proprietor ____Other: Company Classification: (select all that apply) ____ASP ____ISP ____Reseller ____VAR ____System Integrator ____Consultant ____Education ____OEM ____Developer ____Franchise ____Distributor ____Hosting ____Other: Vertical Markets Served: (select all that apply) ____Construction ____Education ____Financial ____Government ____Healthcare ____Home/Residential ____Legal ____Logistics ____Manufacturing ____Non-Profit ____Publishing ____Real Estate ____Retail ____SMB ____Transportation ____Telcom / ISP ____Other: Core Business Focus: __________________________________________________ Geographic Markets Served: (select all that apply) ____Local ____Regional ____National ____International List Top 5 Countries Served: __________________________________________________ Anticipated Annual Volume of BackupChain Licenses: Previous Fiscal Year Revenue % Breakdown: Software: ____ % Hardware: ____ % Services: ____ % ====================================== Current Product Interest ====================================== Time frame for purchase: ____Immediately ____2 - 4 Weeks ____1 - 3 Months ____No immediate purchase needs Seats / licenses required : ____1 - 10 ____11 - 50 ____51 - 100 ____101 - 1000 ____1000 + ____Enterprise / Unlimited ====================================== Company Departmental Contact Information ====================================== Accounting Contact: Phone: E-mail Address: Purchasing Contact: Phone: E-mail Address: Sales Contact: Phone: E-mail Address: Technical Contact: Phone: E-mail Address: ====================================== Marketing and Expected Use Information ====================================== 1. How do you plan to market BackupChain applications? Will you post BackupChain product logos or links to the BackupChain web site on your web site? 2. Are BackupChain applications to be integrated with a new or existing service or product? Please describe the service or product. 3. Are you able to respond to customer inquiries for local reseller pricing that are forwarded from our office? 4. Will you process software only sales to local end users? Do you have any order minimums or restrictions? 5. Is your technical point of contact able to provide 1st level support of BackupChain applications for your customers? 6. How did you become aware of BackupChain applications? Which search engine did you use to find us? What search words did you use? ====================================== Comments: