Become an elligence Partner

If you offer a world-class product or service that would benefit healthcare providers, we encourage you to contact us by completing our Affiliate Application.

We encourage you to fill out each field completely and accurately. This will help us better determine the best way to proceed in establishing an affiliation with your organization.

Name: *

Company:

Position:

Email Address: *

Street Address:

Street Address 2:

City:

State:

Phone:

Fax:

Web Site:

Corporate Information

Year Founded:

# of Clients:

# of Employees:

# of Sales Reps:

# of Support Reps:

Vertical Market Focus

Business Types:

Medical

Accounting/Legal

Small Business

Typical Client:

If you service the medical field, please describe a typical client.

Products / Services

Your Products/Services:

Please give us a brief summary of products/services currently offered by your organization. If you'd rather indicate an URL that describes your product & service offerings, please indicate.

Your Distribution:

Please indicate how you currently sell or distribute your products/services (e.g., direct sales force, resellers, distributors, e-commerce site).

Other Information

Please describe the affiliation or alliance are you thinking about

Other Info:

Become an elligence Partner

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