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At AMD Telemedicine, we consider partners like you a natural extension of our Company. By working closely together and aligning our efforts and strategies, we can increase the quality and profitability of the telemedicine solutions you sell. When you partner with AMD, you'll receive the training, support, and tools you need to reach a level of salesmanship, technical skill, and support expertise that sets you apart from other resellers.

Whether you're an independent VAR, operating system platform designer, video conferencing platform provider, large telecom service provider, or somewhere in between, you'll find that a partnership with AMD has numerous benefits, and positions you at the forefront of the technological revolution in healthcare. If you would like to become an AMD reseller, please complete the application below and take the first step to join us.

While many companies boast of their commitment to partners, we put ours in writing through Partner Principles created specifically for our Reseller Partners. Our Partner Principles clearly state our commitment to collaborate with Reseller Partners in selling products and services. The Principles provide a foundation for predictable and fair behavior in a world that can be anything but. You'll know how best to collaborate with AMD Telemedicine and to access AMD Telemedicine's many resources designed to enhance business success.

We'll work together in a business relationship built on trust that encourages communication, eliminates confusion, and enhances profitability.

Reseller Partner Program - Application Form

Headquarter Information:

* required

Company Name : *
Address : *
Address2 :
Address3 :
City : *	State/Province : *	Zip/Postal Code : *
Country : *
Phone Number : *	Ext. :	Fax Number :
Website :

Primary Contact :

First Name : *
Last Name : *
Title : *

Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Country : *

Phone Number :
Ext. :
Fax Number :

E-Mail Address : *

Sales Contact :

Same Information as: NONE Primary Technical Marketing

First Name :
Last Name :
Title :

Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Country :

Phone Number :
Ext. :
Fax Number :

E-Mail Address :

Technical Contact :

Same Information as: NONE Primary Sales Marketing

First Name :
Last Name :
Title :

Address :

Address2 :

Address3 :

City :
State/Province Zip/Postal Code

Country :

Phone Number :
Ext. :
Fax Number :

E-Mail Address :

Marketing Contact :

Same Information as: NONE Primary Sales Technical

First Name :
Last Name :
Title :

Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Country :

Phone Number :
Ext. :
Fax Number :

E-Mail Address :

Company Statistics :

Primary Activities :

Year Established :

Total Company Revenue (last fiscal year in $ US):

% of Revenue from Telemedicine and related products :

#of Employees #Sales #Technical

Banking Reference :

Bank Name :
Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Country :

Phone Number :
Fax :

Acct. Number :
Contact :

Accountant Reference :

Name :
Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Phone :
Fax :

Contact :

Trade Reference :
(You must supply 3)

Trade Reference 1 :

Trade Reference 1 :
Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Phone :
Fax :

Contact :

Trade Reference 2 :

Trade Reference 2 :
Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Phone :
Fax :

Contact :

Trade Reference 3 :

Trade Reference 3 :
Address :

Address2 :

Address3 :

City :
State/Province :
Zip/Postal Code :

Phone :
Fax :

Contact :

Dun & Bradstreet Number: :

Specialization in Technology/Solution(s) :

Medical Devices
Hospitals
Physicians

Internet Access

Telecommuting/Mobile Computing

Networked Multimedia

E-Commerce

Software

Video Conferencing Facilities

Other

Medical Device Distribution :

Are you a distributor for any other medical device manufacturer or supplier?
Yes No

If you checked "Yes" please list the manufacturer/supplier, the medical specialty, and name of device.

Manufacturer/Supplier :
Medical Specialty :
Device :

Manufacturer/Supplier :
Medical Specialty :
Device :

Manufacturer/Supplier :
Medical Specialty :
Device :

Videoconferencing Facilities :

Yes, on site No

By checking the box noted below, the Applicant expressely authorizes AMD to contact all banking, accountant, and trade references, and to conduct a credit review including a disclosure of financial and credit information relating to the Applicant. The Applicant also agrees to hold AMD harmless for any loss, damage or cost to the Applicant related to any of such reviews conducted in good faith.

I Agree

The Applicant certifies that all of the information set forth in this application is true and correct to the best of its knowledge, and the application contains no information which is false or misleading. The Applicant understands that AMD will rely on this information to process its application. The Applicant agrees to update any information on this application and to give prompt notice to AMD whenever more current information is available.

I Agree

The individual executing this application on behalf of the Applicant has been authorized by the Applicant to provide all information required by the application and to submit this application on behalf of the Applicant.

Name of Applicant:

After completing this form, please press the Submit Form button.

* required

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