Now you can become one of us - a Microform Authorized Reseller!  Please use the form below to tell us about yourself, your company and your plans for selling Microform scanners.  We will review your application and respond as quickly as possible.  

Company Information

Company Name:                  

Your Name:                         

Your Title:                           

Phone Number:                    

Email Address:                    

Mailing Address:                  

Address:                             

City:                                      

State:                                         Zip Code:

Business Information: 

Business Type:                   

Primary Line of Business:    

Products Currently Sold:     

Services Offered:               

Which of the following hardware products are you authorized to sell?

Kodak            Bell & Howell          Canon         Fujitsu         Scan Optics     Other

Number of Employees:                  

Annual Revenue in Dollars:            

Percentage of Sales in Hardware:  

Percentage of Sales in Software:   

Percentage of Sales in Services:    

Please tell us briefly how you plan to promote and sell our products: