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MARKETING PARTNERSHIP REGISTRATION FORM

To register for our Marketing Partner Program, please print this form, complete all the information below, sign and fax to Great Works Internet at 207-282-5036. You can also mail this form to GWI, Attn: Sales Department, 8 Pomerleau Street, Biddeford, ME 04005.
Name:

Email Address: (e.g., johndoe@gwi.net)

GWI Username/Login: (e.g., johndoe)

Company Name:

Type of Company: (e.g., computer sales, web design)

State Tax ID#/Reseller ID#/Social Security#:

Street Address:

City:

State:                                                                     Zip Code:

Telephone Number:

URL (Web Address):

Comments or Questions:





Signature:                                                                                     Date: