Partner Application

Contact Information
Date*
Date Format: MM slash DD slash YYYY
Company Name*
Name*
First Last
Job Title*
Division/Department
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone*
Fax
Email*
Additional Locations
If you operate out of multiple locations, please provide a separate listing of the addresses and contact information for those locations.
City State Zip
Company Information
Company Phone Number*
Company Website*
Principal Officer (CEO/President)*
First Last

Business Information
Years in Business
How many employees do you have in the following functions?
Sales (outside/field-deployed)*
Sales (inside/call-center-deployed)*
Service*
Marketing*
Technical Support*
Other*
Total Number of Employees
How did you hear about our Partner Program?*
Which products of Brother Mobile Solutions are you most interested in reselling?*
- PocketJet Printers
- RuggedJet Printers
- Mprint Printers
- PT-P900/950
- TD-4000/4100
- TD-2020/2120/2130
Have you sold any of these products before?*
- Yes
- No
Which products have you sold before?
Select all that apply (ctrl+click)
Do you have a customer wanting to purchase these products from you now?
- Yes
- No
What products and quantities does your customer need?
Use the plus (+) icon to add additional fields
Product Quantity
Are you responding to a bid for one of the above listed products?*
- Yes
- No
Which products are you responding to a bid for?
Select all that apply (ctrl+click)
What do you expect your annual sales to be on any of the following products to be?
PocketJet Printers*
Please enter a number greater than or equal to 0.
RuggedJet Printers*
Please enter a number greater than or equal to 0.
Mprint Printers*
Please enter a number greater than or equal to 0.
PT-P900/950*
Please enter a number greater than or equal to 0.
TD-4000/4100*
Please enter a number greater than or equal to 0.
Total Sales

Annual Revenue*
- Less than $5M
- $5M-20M
- $20M-50M
- $50M-100M
- $100M+
Percentage of Sales
Hardware*
Software*
Services*
Total Percentage
Must equal 100%
For overall sales, what percentage is from printers, media, and printer services?*
Your company is considered to be a:*
- Consultant
- Distributor
- Hardware Dealer
- Software Developer
- Solution Provider
- System Integrator
- Value Added Reseller
If you are a distributor, do you only sell to resellers?*
- Yes
- No
If you are a reseller, do you only sell to end-user customers?*
- Yes
- No
Distributor Relationships*
Please mark all that apply
- Azerty
- BlueStar
- D&H Distributing
- Horizon
- Ingram Micro
- ScanSource
- Synnex
- Tech Data
- Other
- None
If 'Other', please specify*
Your Vertical Market Focus Areas*
Please mark the top 5 by sales revenue
- Accounting
- Automotive
- Banking/Finance
- Construction
- Education
- Government (Federal)
- Government (State/Local)
- Healthcare
- Hospitality
- Insurance
- Legal
- Manufacturing
- Mobility/Field Workforce
- Pharmacy
- Publishing
- Public Safety
- Real Estate
- Retail
- Route Accounting
- Security
- Telecom/Utility
- Transportation
Application software packages that you develop or integrate
Please name the top 3 by sales revenue
Software Package Percentage of Sales Revenue
Comments
This field is for validation purposes and should be left unchanged.

Contact Information

City	State	Zip

Product	Quantity

Software Package	Percentage of Sales Revenue