Dealer Questionaire

If you are interested in becoming a reseller of Practice Partner software, please complete the form below. Thank you.

Company Name:
Address:
City:
State:
   
Zip:
Telephone:
Fax:
E-mail Address:
Year Founded:
Number of Employees:
Sales Territory:
Number of Sales Representatives:
Outside:
Inside:
Network Experience:
Windows 9x Novell Netware
Windows NT/2K/XP Citrix Metaframe
Do you currently offer healthcare-related software solutions?:
 Yes
No
 If so, what:
Why do you want to be a Practice Partner Dealer?
Contact: