Licensee Registration Form - Value Added Reseller Program

This registration page is for companies that wish to become a Value Added Reseller ("VAR") for the JAZreturns conversion tracker service.

You may only complete this form if you have previously contacted e-JAZ regarding the possibility of your company being a VAR of the JAZreturns conversion tracker service. If you have not previously contacted e-JAZ in that regard, please contact us first.

Fields marked with * must be completed.

Your Company Details

Company Name *
Company Street Address *
Street Address*
City/Suburb*
State/Province*
Zip/Postcode*
Country*
Company Postal Address
Postal Address*
City/Suburb*
State/Province*
Zip/Postcode*
Country*
Company Phone Number*
Company Fax Number*
Company Website URL*
Your primary contact person*

Name
E-mail
Position Title

Accounts e-mail address

(e-JAZ will send information about account changes to this e-mail address)
Billing e-mail address
(e-JAZ will send the monthly bill to this e-mail address)
Authorised Company Officer*

Name
Position Title
(The person in your company who has authorised your company to enter into this agreement eg. CEO,COO, Director)

Support phone number
(We recommend international format)
Support e-mail address
(Your clients will e-mail this address with support problems)
Support URL
(A contact us page, or a page with support information on it)
   
Terms

I agree to the terms listed above*