* Mandatory Fields

Dealer Access Request Form

New Dealer:
Company Name: *
Dealer Number :
Contact: *
Phone: *
Fax:
Email: *
Buyer:

Type of computer: *	IBM compatible		Mac	Other
Browser Used: *	Internet Explorer		Firefox	Other
Web Access Speed: *	14.4 kbs	28.8 kbs	56 kbs
	Cable	DSL	Don’t know	Other
Screen Display Resolution: *	640x480	800x600	1024x768	Other
Purchasing Application Used: *	Lars	Vantage	Light Speed
	Counterman			Other

CONFIDENTIALITY AGREEMENT

All the information displayed on the KIMPEX INC. web site (http://kimpex.com) is proprietary information of KIMPEX INC. and cannot be disclosed without the written authorization of KIMPEX INC. The USER NAME and PASSWORD assigned to your account are also private and cannot be disclosed to any third party without the written authorization of KIMPEX INC.