Partner Inquiry Application

Partner Information Form

1. Company Information

Corporate Name D/B/A:*




ZIP/Postal Code:


Phone Number:*

Fax Number:


2. Contacts

Contact Name:*

Main Contact Email:*

CEO/President Name:

CEO/President Email:

Technical Support Manager Name:

Technical Support Manager Email:

3. Description of your Business

Date Established:

Additional Office Locations:

Company's prior year annual sales:

Company's projected revenue for this year:

4. Number of full-time employees


Sales Reps:

Sales Reps Dedicated to PracticeSuite:

Technical Support Staff:

Technical Support Staff for PracticeSuite:

5. Business Model (identify major focus)

Your company's current vertical focus (Check all that apply):

Does your company offer (Check all that apply):

Principle value provided by your company to its customers:

Current Business Relationships/ Alliances/Certifications:

Please list the geographic areas served by your company:

Who are your competitors in the markets that you plan to sell PracticeSuite products?:

Please tell us why you would like to become a PracticeSuite Reseller (max 100 words):

Please provide one customer reference that we can contact: