Sorry, the E-Mail field can not be left blank."; } else { //Do the form process $bodymessage = "Reseller's Application\nGenerated by www.chemusa.com\n\nCompany Name: $Company_Name\nAddress: $Address_Line1 $Address_Line2, $City, $State_Zip\nPhone: $Telephone\nFax: $Fax\nWeb Site: $Web_Site\nContact Name: $Contact_Name\nContact Position: $Contact_Position\nEmail: $email\nExperience With Noetbooks? $Experience_with_Notebook_Sales\nExperience With Desktop Sales? $Experience_with_Desktop_Sales\nReseller Number: $Resellers_Number\nCompany Information: $Company_Information\n\nHistory1 Date: $History1_Date\nHistory1 Brand: $History1_Brand\nHistory1 Volume: $History1_Volume\nHistory1 Territory: $History1_Territory\n\nHistory2 Date: $History2_Date\nHistory2 Brand: $History2_Brand\nHistory2 Volume: $History2_Volume\nHistory2 Territory: $History2_Territory\n\nHistory3 Date: $History3_Date\nHistory3 Brand: $History3_Brand\nHistory3 Volume: $History3_Volume\nHistory3 Territory: $History3_Territory\n\nHistory4 Date: $History4_Date\nHistory4 Brand: $History4_Brand\nHistory4 Volume: $History4_Volume\nHistory4 Territory: $History4_Territory\n\nHistory5 Date: $History5_Date\nHistory5 Brand: $History5_Brand\nHistory5 Volume: $History5_Volume\nHistory5 Territory: $History5_Territory"; mail("sales@chemusa.com", "Reseller's Application", $bodymessage); $mess = "Thank you, your Reseller's Application has been processed."; } } ?>

$mess

";} ?>
Download the Reseller Application Form and Credit Application Form in Word97 Format

Company Information

Company Name
Address (Line 1)
Address (Line 2)
City
State and Zip Code
Phone Number
Fax Number
Web Site Address
Contact Name
Contact's Position
in Company
E-mail Address
(Required)
Computer Sales
Experience		 Experience with NoteBook Computer Sales
Experience with Desktop Computer Sales
Reseller's
Certificate Number
Company
Information
(Optional if you
have a web site)

Sales History


 		Dates Brand Name / Model Volume Territory
1.
2.
3.
4.
5.

Please make certain that your e-mail address has been entered correctly!
A correct e-mail address is necessary for us to respond to your application.

Be sure to complete a Credit Application form, and fax it to us at (510) 608-8829.

 

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