Distributor Application Form
Please provide some information about your company.
Trade or business name:*  
Sole Owner
Partnership
Corporation
Incorporated In:  
How long in business:  
Street:*  
ZIP Code, Town:*  
State, Country:*  
Telephone number:*  
Mobile Phone number:  
Fax number:  
Skype:  
Messenger:  
E-mail:*  
Website:  

Company Profile
President or Owner:  
Service Manager:  
Accounts Payable Manager:  
Financial Manager:  
Sales Manager:  
Authorized to purchase:  
Total employees:  
Field of business:*  
Geographic area:*  
Reference sites:  

Planned Business Activity with IMAGE
Product  Estimated Annual Purchases
iQ-VIEW / PRO  
IQ-3D  
IQ-WEB  
iQ-PRINT  
iQ-FORWARD  
iQ-GATEWAY  

Tax Data
Country Tax ID #:  
EU VAT no.:  

Bank Reference
Principal bank:  
Contact:  
Address:  
   
Account number / IBAN:  
Phone number:  
Routing # / BIC:  
Where did you hear about us?:*  
General comments: