MOFI NETWORK
CANADIAN DEALER APPLICATION

Your Company Name

Web Site, ex. http://www.mofinetwork.com

Email Address

Contact Person

Contact Phone Number

Address

City

Province

Postal Code

Phone Number

Do you resell to dealers?

Yes
No

PST Number (Ontario Dealers Only)

Do you have a retail store?

Yes
N0

If so, how many?

Enter retail store(s) address if applicable

Do you currently sell other 3G routers, if so which brands?

Do you currently sell other powerline adaptors, if so which brands

Approx how many units do you plan on purchasing at a time?

Do you want to be listed on the MOFI web site?

Yes
No

Comments

Attachment if needed: