Reseller Application – Bongo Technologies

Name*

First Last

Title*

Primary Phone*

Email*

Shipping Address

Street Address City State ZIP Code

Billing Contact Name

First Last

Billing Address*

Street Address Address Line 2 City State ZIP Code

Billing Phone

Billing Email

FEDERAL EIN*

D&B D-U-N-S

Are you a part of a franchise?*

Franchise Name*

Total # of Locations*

Total # of Field Technicians*

Your Industry*

Elevator Company

Security Dealer

Contractor

Other

Your Territories/Regions*

Name of Person Submitting Application*

Date*

Name

This field is for validation purposes and should be left unchanged.