subject_line
Company Information
Trade Name
*
Street Address
*
Address Line 2
City
*
State/Province/Region
*
Zip/Postal Code
*
Country
*
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czechia
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Phone Number
*
Email Address
*
HST/GST/Federal ID#
Legal Structure
*
Corporation
Partnership
Sole Proprietor
LLC
Other
Other
Website Address
Twitter Account Name
Facebook Account Name
Year Established
*
# of Employees
*
1-5
6-10
11-25
25-50
50+
Gross Annual Sales
*
Less than 250K
250K-500K
500K-1M
1M-3M
3M-5M
5M-10M
More than 10M
What type of Customer Account would you like to open?
*
End User (Purchase for own use)
Retailer
Distributor
VA Reseller/Corporate Reseller
3rd Party Online Reseller
Internet Service Provider
What best describes your business location?
*
Retail Store
Office/Warehouse
Online
Home-Based/Off-Site Service
Kiosk
What industry or industries are you in ?(Choose as many that apply)
*
Advertising & Promotional
Apparel
AV/Stereo/Electronics
Camera/Go Pro
Cellular Sales/Repair
Closeouts and Auctions
Computers/Computer Repair
Department stores
Dollar stores
Education
Food/Drug/Convenience
Furniture & Appliance
Government
Health & Beauty
Hospitality
IT Managed Services
Luggage & Travel
Not for Profit
Office Supply
Sports/Outdoor/Leisure
Toy & Hobby
Other
Special Needs
Giftware
If you do Cellular Sales which Carriers do you represent?
No I am strictly repair
Bell Mobility
Eastlink
Fido
Ice Wireless
Koodo
MTS Mobility
Public Mobile
Rogers Wireless
Sasktel
Sugar Mobile
Tbaytel
Telus
Videotron
Virgin Mobile
Wind Mobile/Freedom Mobile
Chatr
Shaw Direct
Xplornet
Other (Please Specify)
Other (Please Specify)
Otterbox/Lifeproof Authorized - CANADA ONLY
Yes (Application Submitted and Approved)
No but we would like to be
No we don't need it
Otterbox/Lifeproof Authorization Link
Do you belong to any buying groups?
*
Yes
No
Which of these buying groups would you belong to? (Check all that apply)
Dont know
AVU Audio/Video
ASCII Group
Cantrex
Coopsco (Quebec)
CANCOLL
CRC
CSCEX
Group Millenium
Megagroup
Power Group
Super Micro
The Guild Stationers
Smcorp
Other (Please specify)
Other (Please specify)
Billing Information
Bill To
Same as Company Address
Billing Address
Address Line 2
City
State/Province/Region
Zip/Postal Code
Country
Billing Contacts for Invoicing/Statements
Billing Contact #1
Phone Number
Ext
Email Address
Billing Contact #2
Phone Number
Ext
Email Address
Payment Method
Wire
Email Transfer
Cash
Credit Card(Can also be provided at a later time)
Net Terms
Other (Please Specify)
Other (Please Specify)
Credit Card Type
Visa
Mastercard
Name on the Card
Credit Card Number
Exp
Signature for Credit Card Authorization
clear
Shipping Information
Ship To
Same as Bill To
Is this a Residence
Yes
No
Shipping Address
Address Line 2
City
State/Province/Region
Zip/Postal Code
Country
Shipping Contact for Tracking Details
Shipping Contact #1
Phone Number
Ext
Email Address
Shipping Contact #2
Phone Number
Ext
Email Address
Buyer Information
Buyers Name #1
Phone Number
Ext
Email Address
Buyers Categories (Check all that apply)
*
Audio Speakers & Headphones
Cellular Cases & Accessories
Closeout Product
Ergonomics
Gaming Accessories
Home & Office Essentials
Keyboards & Mice
Laptop Bags & Accessories
Luggage & Sport Bags
Mounting and Docking
Power Solutions - Wall, Car Chargers & Cables
Refurbished Computers & Laptops
Screen Protection
Seasonal Gift & Promotional Items
Signal Enhancing
Tablet Cases & Accessories
TV Android Boxes & Accessories
Video Console Games & Accessories
Software Antivirus & Security
Software Applications & Utilities
Software Licensing Eset
Software Licensing Malwarebytes
Software Licensing Panda
Networking
I would like to receive special offers/promotions and updates when available via email.
Buyers Name #2
Phone Number
Ext
Email Address
Buyers Categories (Check all that apply)
Audio Speakers & Headphones
Cellular Cases & Accessories
Closeout Product
Ergonomics
Gaming Accessories
Home & Office Essentials
Keyboards & Mice
Laptop Bags & Accessories
Luggage & Sport Bags
Mounting and Docking
Power Solutions - Wall, Car Chargers & Cables
Refurbished Computers & Laptops
Screen Protection
Seasonal Gift & Promotional Items
Signal Enhancing
Tablet Cases & Accessories
TV Android Boxes & Accessories
Video Console Games & Accesories
Software Antivirus & Security
Software Applications & Utilities
Software Licensing Eset
Software Licensing Malwarebytes
Software Licensing Panda
Software Licensing Panda
I would like to receive special offers/promotions and updates when available via email.
Have you been in contact with a member of our Sales Team?
*
John Ivankovic
Jason Sack
Helen Koutsogiannopoulos
Brian Jacob
Josee Doucet
Zorana Vagic
Richard Lee
Dave Vettese
Ashish Gudhe
Not Yet
Don't Remember
How did you hear about us?
*
Email Marketing
Printed Mailout
Web Search
Facebook
Twitter
Instagram
LinkedIn
Employee Visit or Call
Customer Referral
Vendor Referral
Seminar/Tradeshow
Public Relations
Other
Other
Help us get to know your floor space with a store image.
Contact details for the person submitting the form
First Name
*
Last Name
*
Title/Position
*
Email Address
*