- edgehealthsolutions.com -- VAR signup form -

All information herein must be filled out in its entirety and under the applying VAR’s or Consultant’s notarization as to the truthful nature of all information entered. Submission of any falsified information will result in the application being declined, de-certification, and/or legal action as a direct result of the impact of said information on EHSI. All information collected is protected under EHSI’s Privacy Policy. To review this policy click here or contact us.

VAR Information
(Information concerning the corporate office or principle location of business)
Full Legal Business Name *
Other Business Name(s) Used (DBA)
Please separate names with a comma.
Address 1 *
Address 2
Suite / Unit
City *
Province / State *
Postal Code / ZIP *
Country *
Phone *
Fax *
E-mail *
URL
Accounts Payable Contact Name *
A/P Contact Phone *
Billing Location
(Location below will receive invoices for all chargeable fees from EHSI)
Same info as above? *	Yes No
Full Legal Business Name
Other Business Name(s) User (DBA)
Please seperate names with a comma.
Address 1
Address 2
Suite / Unit
City
Province / State
Postal Code / ZIP
Country
Phone
Fax
E-Mail
Accounts Payable Contact Name
A/P Contact Phone
Relationship Benefit
What makes you and/or your business unique and a desirable addition to the partner team?
What is your market focus? Check all that apply	Dental Medical Digital Radiography Optical Laser Clinic Botox™ Clinic Other
Other
Do you have experience in these markets?	Yes No
Years of experience
Company Information
Total number of employees
Number of consultants
Number of sales people
Dedicated marketing team
Annual total company revenue ($USD)
What percentage of your revenue is related to reselling?
What percentage of your revenue is related to services?
Apple Related Business Designations? Check all that apply	Apple Authorized Reseller Apple Authorized Service Center Apple Specialist ACN Apple Business Agent ASMC Other
Other
What other authorizations do you have? List all that apply...
1.
2.
3.
4.
5.
What certifications do you hold? List all that apply...
1.
2.
3.
4.
5.
Does your office have a training facility?	Yes No
How did you learn about Edge Health Solutions?
Services Offered. Check all that apply.	System Integration Network Design Site Survey Installation Technical Support Security Analysis Documentation
What networking and/or hardware solutions does your company offer? Check all that apply	VPN Router/Gateway Firewall security Wireless LAN VPN Anti-virus/content filtering Switches - F/E or GigE Voice over IP Network management systems WAN management - load balancing
Are you submitting a business plan with this application?	Yes No
Attach your plan here (max 100kb)
or copy and paste the plan here
Do you have a client currently looking for a dental or medical practice management solutions?	Yes No
Which discipline? Check all that apply	Dental Medical Digital radiography Optical Laser Clinic, BotoxTM Clinic Other
Other
If you answer yes, please tell us about your client
Please type the letters you see in the image

- Privacy Statement -

(Information concerning the corporate office or principle location of business)

Please separate names with a comma.

(Location below will receive invoices for all chargeable fees from EHSI)

Please seperate names with a comma.

What makes you and/or your business unique and a desirable addition to the partner team?