Distributorship Application Form                       
Your information will be treated with the highest degree of confidentiality and our sales representative will contact you shortly to discuss next steps.
Nautilus Hyosung very much appreciates your interest in becoming our strategic Distributor of ATM products in the North America market.

We cordially invite you to be become our Distributor and closely collaborate with Nautilus Hyosung to achieve your business goals and objectives.

Please fill out the following information.
Fields marked with are required.
  Basic Company Information
  Company Name :
  Owner or President Name :
  Address1 :
  Address2 :
  City :
  ZIP Code :
  States(US) :   Province(CAN) : 
  Country :
  Contact Name :
  Phone1 :  -  -   EXT.  
  Phone2 :  -  -
  Fax :  -  -
  E-Mail : @
  Website : http://
  Additional Company Information
  Type of Organization : Sole Proprietorship LLP/LLC Partnership Corporation
  States(US) of Incorporation :   Province(CAN) : 
  Country of Incorporation:
  Date of Incorporation :
  Federal Tax ID No. :
  Corporate State ID No. :
  Reseller Permit Number :
  Years in Business : yrs
  Years in ATM Business : yrs
  DUNS Number(D&B) :
  ATM Business Information
  Are you currently selling ATMs? : Yes No
If yes, which ATMs are you selling? :
(please provide all vendors)
Triton  Tranax  Tidel  NCR  Diebold 
Wincor  Others  - please specify 
If you are currently Tranax or Triton dealer,
what type of partnership are you? :
Tranax -  Elite Master Regular
Triton  -  Admiral Others
Others -  please specify 
  Annual Sales Volume in 2007 :  Units     USD
  Do you provide your own service? : Yes No
  Who are your major processors? :
(please provide us all of processors)
  Processor Account Number :
  Contact Information for Account
Managers of Your Major Processors :		 Processor Name : 
Your Account Manager Name : 
Telephone :  -  -
What models of our machine are you
interested in? :
(please select all applies)
NH-1500  
NH-2100T  
Monimax 7000D(NH-5000)  
Nanocash 2000  
Nanocash 3000  
Monimax 5100T(NH-5040)  
Monimax 5000CE(NH-5050)  
Monimax 5000CE(NH-5050 sidecar with kiosk function)  
Monimax 5600(NH-5090)  
Monimax 7100T(NH-7040)  
Monimax 7600D(NH-7070)  
Monimax 5100(NH-9030)  
Monimax 5100(NH-9030 Deposit Only)  
※Please refer our website for specification of each model.
Comments or Questions :
Submit  Clear
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