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VAR / Rep Application Form

*First Name, *Last Name
*City, *State/Province
*Zip/Postal Code *Country
*Email Address
*Telephone Number
*EIN/SSN (?)
Master Agent (if known)

By clicking on the Submit button, you acknowledge that you have read, understand, and will abide by the
terms and conditions of the Sales Agency Agreement, and will sign and send same to JV/M at the address below.

The Lead Generator is a service of and JV/M, Inc.
1221 N Church Street, Suite 202 • Moorestown, NJ 08057
856-638-0399 •