MEDIASOURCEŽ V-MAIL AFFILIATE and RESELLER APPLICATION We are looking for a few key affiliates and resellers to market and reap the benefit of this Break-a-way Technology sevice. If you have marketing and some technical skills and are interested in becoming part of this truly ground floor opportunity, please tell us about yourself on the form below. We will get back to you by email with our response. First Name Last Name Company Name Address Line 1 Address Line 2 City State Zip Code Country Daytime Phone () - Fax () - E-mail Address Your Internet Provider: Your Website URL: Comments Size of Your Market Area How Long in Business What Products or Services do you now offer? Products and Services Tell us Something about your business Other Affiliations