CareMed Reseller Application

Name:_______________________________________________________________________

Company:____________________________________________________________________

Address:
____________________________________________________________________________
____________________________________________________________________________
City:____________________________________________State:	_______	Zip:________

Email address:______________________________________________________________

URL address:________________________________________________________________ 			
Daytime Telephone:	(________)________________ Fax: (_______ )__________ 

Please include the following with this completed application:

1. A copy of your valid state reseller tax certificate.
2. A description of your company and the services you provide.
3. Any available company literature.

Please complete the following information:

Number of Years in Business:________________________________________________
Number of Employees:________________________________________________________

What geographical area do you cover?
____________________________________________________________________________
____________________________________________________________________________

Company's Annual Gross Sales: (Please check one of the following).
* Less than $100K
* $100K-$500K
* $500K-$1M
* $1M-$10M
* Over $10M

Percent of revenues from healthcare providers:  _________
List medical software that you currently resell:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________


Do you sell competing EMR software?    Yes _____ No  ____ If yes, please list which ones:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Please check the services you plan to offer:

* Med ProFile(r) user training
* Med ProFile(r) customization
* Med ProFile(r) Basic user support 
* Med ProFile(r) Advanced User Support
* Other: 

If you plan to offer user support please check the type of support.

* Telephone Support	
* On-Site Support	
* Contract Support
* Other: 


Thank you for applying to be a Med ProFile(r) reseller.  

Please return this form to CareMed at:

E-mail: caremed@inetworld.net 

Fax: 	Attention CareMed at (619)698-0609 

Mail:  	CAREMED CORPORATION
BLDG 2 STE 2
5565 GROSSMONT CENTER DRIVE
LA MESA CA 91942