Reseller Application Form

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Your Name *

Company *

Trading As (if applicable)

Phone *

Fax

Website

E-mail Address *

Nature of Business *

Accounts Contact Name *

Accounts Contact Phone *

Accounting Address *

Delivery Address *

Registered Office *

Registered Number *

Registration Date *

Company Type *

Parent Company
If your company is a Subsidiary, please enter the name of the Parent Company.

Names of Directors / Proprietor / Principal Partners *

Would You Like a Login and Password to Our Website?
If you select yes, we will create you a reseller account so that your reseller discount is automatically applied when using the website to order items.

Click to answer Yes

Requested Website Username
We will create an account for you with this username. We will create an initial random password for you. You will be able to change this password when you log in to the site.

How Did You Hear About Us *

Disclaimer
I hereby submit the above information for the sole purpose of opening a Reseller account with IPChitChat - a trading name of Autonomy Business Solutions Ltd. I acknowledge that all orders are accepted by IPChitchat in accordance with their Terms and Conditions of Sale and agree that my company shall be bound by them in all transactions. I have read the Terms and Conditions of Sale (which I acknowledge may change from time to time) and agree to abide by them in full.

Select if you agree