Dealer Application

Business Details

Registered Name *

Registered Name * *

ABN/ACN *

Company Phone *

Annual Turnover *

Under $1 million

$1 – $3 million

$3 – $6 million

$6 million +

Trading Name *

Year Of Establishment *

Website *

Number of Employees *

1 – 3

4 – 10

11 – 20

21+

Sales Forecast 1 Month *

Sales Forecast 3 Months *

Sales Forecast 1st Year *

Contact Details

First Name (Main Contact) *

Email Address (Main Contact) *

Last Name (Main Contact) *

Email Address for Monthly Dealer Newsletter *

Shipping Details

Shipping Street Address *

Shipping State *

Email Address for Shipment Tracking Numbers *

Shipping City *

Shipping Postal Code * *

Billing Address *

First Name (Accounts Contact) *

Last Name (Accounts Contact) *

Email Address (Accounts Contact) *

NATURE OF BUSINESS

We want to be able to send you relevant information and leads in those areas you are interested in. To choose multiple areas of interest click “Ctrl” and use your mouse to select more than one line.

What industry best describes your business *

Nature of Business Other *

ARE YOU AN INSTALLER

What industry best describes your business *

Installer Other *

WHAT AREAS DO YOU SERVICE?

What Areas Do You Service? *

Areas Other *

PRODUCTS OF INTEREST

So we can provide you with sales and training information please select the products of interest below. *

PRODUCTS OF INTEREST

How Did You Hear About Us? *

Other *

Sales Representative *

TERMS & CONDITIONS OF SERVICE

Click here to read the Terms & Conditions of Service

I agree to the Powertec Terms & Conditions of Service *

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Modems

Modem Routers

Wireless Modules

Others

Business Details

Contact Details

Shipping Details

NATURE OF BUSINESS

ARE YOU AN INSTALLER

WHAT AREAS DO YOU SERVICE?

PRODUCTS OF INTEREST

PRODUCTS OF INTEREST

TERMS & CONDITIONS OF SERVICE

Title

Intercel Pty Ltd