Representative/Partner Application

To have opportunities to become a representative/ reseller in the following region, please fill in the form

1. Indonesia

2. Vietnam

3. Thailand

4. Philippines

5. India

All fields are required

Company

Name

Address

Title

Phone number

Fax

Email

Website

No. of Sales person

Current Products/Vendors Represented

No. of Years in Business

Industries covered:

Electronics Micro-Electronics Aerospace Medical Optical Telecommunication Jewelry Furniture

Others (please specify)

Last 3 years revenue(USD):

2006

2007

2008

(estimate)

Reference

Credit (3 required)
(seperate by comma)

5 Major Customer
(seperate by comma)

Brief outline of goals and marketing plan for our products

How did you find out about us?

Location where you intend to represent us?

Country

City

Please email your latest organization chart to mkt@blaze.com.sg