GEOBIS INTERNATIONAL - Geographic Business Intelligence Solutions


	Geobis International PBX (305) 395-3772 Fax (305) 397-1461 5201 Blue Lagoon Drive 8th Floor Miami, Florida 33126 USA geobis@geobis.com

	BE AN AUTHORIZED DISTRIBUTOR

	Please complete the form below and be part of the selected group of Companies that distribute our products and services worldwide

	* First name
	* Last name
	* Organization / Company
	Commercial Area
	Occupation / Position
	* Phone number and extention
	Fax
	* E-mail
	Address
	* City
	State / Province
	Zip Code / Post Code
	* Country
	Website HTTP://
	Industry Segment

	*Employees' Number

	* Annual Sales - US $
	Number of Actual and Active Customers


	Number of Customers attended in all Company's History.
	* Products you want to Distribute
	* Products you want to Distribute
	How did you hear about us?

	*Banking References (Bank Name - Contact Name - Account Number - Address - Phone - Email)

	*Commercial References (Name - Address - Phone - Email)

	*Why do you want to be our Distributor

	*Comments / Questions