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  Partner Application
To become a HipaaManager Partner, please complete the following form:

Business Information:
Company
Address
City
State
Zip
Business Phone
Fax
Web Site URL   ex: www.mysite.com

Contact Information:
First Name
Last Name
Title
Personal Phone
Email


Business profile:
1. Which best describes your company's PRIMARY business?
Consultant
IT Security
Hardware Reseller
Software Reseller
Speaker/Presentations
Training
Other - description  
What other categories describe your SECONDARY businesses (Check all that apply)
Consultant
IT Security
Hardware Reseller
Software Reseller
Speaker/Presentations
Training
Practice Management Software
Medical Devices
 
2. Geographic Market Served (Check all that apply)
Northeast
Southeast
North Central
South Central
Northwest
Southwest
Canada
Select Cities
Nationwide
Other
 
3. What size organization does your company sell to or service? (Check all that apply)
Fortune 1000
Large (over 1000 employees)
Medium (100-999 employees)
Small (Under 100 employees)
None of the above
What services does your company provide
What hardware products does your company sell
What software products does your company sell
Are you interested in reselling HippaManager's products?
  Yes
 
Enter any additional information that you would like to provide

Thank you for your interest in becoming a HipaaManager partner. A representative will contact you shortly with additional information on getting started as a partner.



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