Company Information

Please provide the information about your company, including a complete mailing address.
 

* Company Name: 

* Address: 

* City: 

Zip/Postal Code: 

* Country: 

Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea-Bissau Guinea Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Korea Dem. People's Rep of Korea Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republi Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Fed. States of Moldova Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Occupied Panama Canal Zone Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Kingdom Unknown Uruguay Uzbekistan U.A.E. U.S.Minor Outlying Islands Vanuatu Vatican City State Venezuela Viet Nam Virgin Islands U.S. Virgin Islands (British) Wallis and Futuna Islands Western Sahara Yemen Republic of Yugoslavia Zaire Zambia Zimbabwe

Website URL:

Please use only digits (0-9) -- no spaces, letters, or punctuation such as "+" or "( )"

* Telephone Number: 

Fax Number: 

Contact Information

Please provide information for the individuals who will be primary contacts for Kofax in the following areas:

Primary Program Contact - this person will receive program information and materials
 

Mr/Ms: 

* First Name: 

* Last Name: 

* Email Address: 

* Phone Number: 

Function/Title: 

Primary Sales Contact - this person will receive sales leads and sales communications
Same as Program Contact
 

Mr/Ms: 

* First Name: 

* Last Name: 

* Email Address: 

* Phone Number: 

Function/Title: 

Primary Technical Contact - this person is the designated technical contact for Kofax Technical Support
Same as Program Contact
 

Mr/Ms: 

* First Name: 

* Last Name: 

* Email Address: 

* Phone Number: 

Function/Title: 

Tell Us More About...

Your Company

Sole Proprietor Partnership Corporation Division Of:

* Primary Line of Business: 

Systems Integrator VAR/Reseller ISV Consultant Service Bureau Other:

Geographic areas served: 

Local Regional National International

Sales Office Locations:  

Development/Support Locations:  

* Length of time in business: 

Less than 1 year 1 to 3 years 4 to 6 years 7 to 10 years Over 10 years

Please indicate the percentage of each of the following  as they contribute to your annual revenues:

Software Sales 

%

Hardware Sales

%

Services

%

Imaging Service Bureau

%

Other

%

Your preferred Kofax Distributor:

AE - Dicom FZE AE - ForeFront Technologies AT - DICOM lnformationstechnologie GmbH AU - Dicom Australia Melbourne AU - Dicom Australia Sydney BE - DICOM Benelux Belgium CH - Dicom AG CZ - DICOM Data Management CZ DE - DICOM Deutschland GmbH DK - Dicom Edb-distribution A/S FI - Dicom Finland Oy FR - Dicom France GB - DICOM Technologies Limited HU - DICOM Magyarország Kft ID - Dicom Indonesia IT - PDS SRL MX - Compucenter De Mexico (CSP) MY - DICOM Malaysia Sdn Bhd NL - Dicom Benelux Netherlands NO - Dicom Norge A/S NZ - Infinity Solutions Ltd PH - Dicom Philippines PL - Dicom Polska Sp.z.o.o. PT - Sistemas DICOM Iberica S.A. SE - NorDICOM AB SG - Dicom Singapore Pte Ltd ZA - Premark Products (PTY) Ltd. / ImageTEK

Your Staff

Total # Employees: 

# Employees
 

Sales:

Service/Support:

Programmers:

Other:

Number of Employees dedicated to imaging:
 

Sales:

Service/Support:

Programmers:

Other:

Networking Certifications: 

MCSE CNE CCNA

Please check the programming languages/development environments your programmers are proficient in:
 

.NET
AppBuilder
ASP
C++
C#

Delphi
IIS
Java
Lotus Notes
Pascal

PHP
Powerbuilder
SQL for Windows
Visual Basic
XML

Your Product Authorizations

Which document management / workflow / content management solutions are you authorized to sell?
 

Other:

 
Which system hardware products are you authorized to sell?
 

Production Scanners / Storage

Bell & Howell
Canon
Fujitsu

HP (Hewlett-Packard)
Kodak (including DAW)
Maxoptix

Panasonic
Plasmon
Ricoh

Multi-function Peripherals (MFPs)

Canon
HP (Hewlett Packard)
Lanier

Lexmark
Ricoh

Savin
Xerox

Your Markets and Your Market Development

Which vertical markets, if any, do you target?
 

Accounting
Banking/Finance
Communications
Education
Federal/Central Government

Health Care
Insurance
Law Enforcement
Legal
Manufacturing

Publishing
Services
State/Local Governement
Transportation/Trucking
Utilities

 
What types of marketing activities do you currently engage in?
 

Advertising
Direct Mail
Promotions

Sales Literature
Seminars
Trade Shows

User Group Meetings
Other

 
PLEASE READ THE FOLLOWING CAREFULLY.
By submitting this form you have read, understood, and accept the terms and conditions as stated below.

 
With the submission of this application and acceptance into the Ascent Certified Reseller program, you ("Reseller") agree to pay the Reseller Program Fee at the then established price published in the current Price List.

Kofax hereby grants Reseller the non-exclusive right to resell the Software to end users and use the Software for demonstration purposes. Reseller agrees in good faith to use best efforts to market, demonstrate, and sell the software products. Reseller agrees to maintain sufficient trained sales and technical personnel certified by Kofax to promote the sale of Kofax products.

Reseller understands and agrees that the source code and object code of the software, all technical information related to the Software, and all knowledge of Kofax's business plans and practices are confidential and constitute trade secrets of Kofax Image Products. Reseller will not disclose, exhibit, reproduce, summarize, sell, or distribute any confidential information to any other person other than the Reseller's agents, employees, and advisors who need to know. Reseller understands and agrees the Reseller Kit dongles are for demonstration and evaluation purposes only and not for resale.

It is understood that Reseller is an independent contractor and not an agent, partner, or joint venture of Kofax Image Products, and may not bind or incur any obligations or liability on behalf of Kofax in any manner whatsoever.

* I Agree to the above Terms and Conditions  Yes