Distributor Application Form (PC/104)

Do you want to become an official Distributor of our PC/104 boards?
Please fill in all data below and we will promtly return with further requirements to become an official representative of our PC/104 modules.

- This company profile will be held stricktly confidential and is only for internal use of Micro Technic

Fields marked with * are required

Company name *
Titulation Mr. Mrs. Ms.

First Name *
Last Name *
Title
Dept
Street *
Zip *
City *
Country *        
Phone No *
Fax No
Email address *
HomePage
Company activity: *
Staff (number of employees): *
Number of salesmen: *
Description of the activities:

Our company is : 
- 100% Integrator:  or
- 100% Distributor  or
-   % Integrator and   % Distributor 

Total Annual Turnover : last year :   US$ 
two years ago:   US$ 

In which sector do you think your company is mostly specialised:   


Sector of Activities - Good - - Fair -  - None - 
Industrial Controls
Machine Builders
Medical Equipment
Optical Equipment
Communnication Equipment
Transportation
Other Industries

Others (please specify):
Extra comments ?

eZ publish™ copyright © 1999-2005 eZ systems as