Become a Partner - Mosaic NetworX

Company Contact Information
Company Name*
Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Website*
Company Email Address*
Company Phone*
Number of Years in Business*
Please indicate the total number of employees in your organization:*

Your Contact Information
Name*
First Last
Business Email Address*
Job Title*
Contact Phone*
Will You be the Primary Partner Contact?*
- Yes
- No
Partner Signatory Contact
Partner Signatory and contact information is the same as above?*
- Yes
- No
Name*
First Last
Business Email Address*
Job Title*
Contact Phone*
Partner Marketing Contact
Partner marketing contact and information is the same as above?*
- Yes
- No
Name*
First Last
Business Email Address*
Job Title*
Contact Phone*

Sales Information
Does your company have a potential Mosaic NetworX opportunity pending?*
- Yes
- No
What were your total annual sales revenues last year?*
Please indicate the number of Outside Sales personnel in your organization:*
Please indicate the number of Inside Sales personnel in your organization:*
Please indicate the number of Sales Engineers (Application/Hardware) personnel in your organization:*
Please select the top 3 industries you are selling into:*
Please specify what percentage of your business is:
(Total should be 100%)
Product Sales
Service Sales
Consulting Sales*
Please indicate if you are an authorized partner of one of the following (select all that apply):
Do you integrate cloud solutions with any of the vendors listed above?*
- Yes
- No
- N/A
What is your primary target market size?*
Tax ID Number*
By submitting this application, the applicant is requesting approval from Mosaic NetworX to procure their services. The applicant acknowledges that Mosaic NetworX may grant or withhold this approval in its sole discretion and, once granted, may terminate its approval for any reason upon thirty (30) days advance written notice. Upon termination of an approval from Mosaic NetworX, the applicant will no longer be authorized to procure Mosaic NetworX services and will immediately cease use of all Mosaic NetworX material, including but not limited to Mosaic NetworX products, marketing materials and Mosaic NetworX trademarks.*
- I acknowledge that I have read and agree with the above statement.
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Company Contact Information

Your Contact Information

Partner Signatory Contact

Partner Marketing Contact

Sales Information

Please specify what percentage of your business is:

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