If you wish to become a FibroLAN partner, please complete this form in full detail.

Some fields are mandatory and the system will not accept your application unless completed.

Remember - the more information you provide us with - the faster your application will be processed.

NEW PARTNER

FibroLAN Partner Program Registration

Please fill-in the requested information to assure fast processing

* - mandatory fields

Contact Information

Company Name*:
Address of HQ/Main Location*:
City*:		State/Country*:
Tel*:		Fax*:
E-Mail*:		Web Site Address*:
Contact Person*:		Function*:

Business Data

Which of the following describes the nature of your business (check one or more)*:
Distributor		System Integrator
VAR		VAD
REP		Consultant
Other, Please specify

Revenues ($M):
# of sales staff*:		# of support staff*:

Branches in other cities/states/countries:
Networking vendors represented*:
Major industries serve:
Credit references:

Business Interest

Preferred mode of collaboration:

Any Other Information Requested:

E-mail: info@fibrolan.com