Looped LOGIC Reseller Registration Form		Date:
Organization Name:
Contact Name/Title:
Email:
Address:
City:  State:  Zip:
Phone:	Fax:
Website:
Describe your Line of Business:
Other Complimentary Products Distributed or Manufactured:
Do You Install?    Yes      No
Check The Markets you sell to (Check all that apply) Education:  Health Care:  Pharmaceuticals:  BioTech:  Government:  Other:
Upon Approval, you will be eligible to receive Reseller discounts.