Reseller Change Request

System Administrator *

First Name

Last Name

Phone

(###)

###

####

Requested Change Date

MM

DD

YYYY

Current Account Representative

First Name

Last Name

Is the reseller aware of your request?

Yes

No

May we inform the reseller of your wishes if they do not already know?

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

New Account Representative

First Name

Last Name

Phone

(###)

###

####

Access to your AppEazy System? *

Would you like us to create a new user account on your AppEazy system under the new Resellers name?

Yes

No

Confirmation *

I acknowledge that I am giving another company access to my AppEazy System and to the data that resides on it. I am also authorizing Applianz Technologies to to work with this company on our companies behalf.