Wufoo

Date * MM / DD / YYYY
Company Name *
DBA
Contact Name *
Physical Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Email *
Website *
Ingram Micro Account Number *

Must be 8 digits (see example)
12-345678
Ingram Micro Account Manager *
Type of Business *
Retailer Custom Integrator VAR/B2B Internet Reseller Transact on a Marketplace
Number of Retail Locations *
Please describe the type of VAR/B2B *
Website Address *
Name on Marketplace *
Name the Marketplace that you transact on (i.e. Amazon, Newegg, Walmart) *
Please check the following to agree *
Will NOT advertise on company website
Please check the following to agree *
No 3rd party marketplace listings or selling including, but not limited, to Amazon, eBay, Walmart, Newegg
Ubiquiti has a policy that prohibits sales of their product on marketplaces such as Amazon, Newegg, Walmart, etc. This policy is being driven by Ubiquiti and Ingram Micro has been asked to enforce it. If you, or your customers, choose to sell on any marketplace platform you are subject to being deauthorized from purchasing Ubiquiti products from Ingram Micro.
By signing this document, you are agreeing to not sell on any marketplace platform. Please put your initials in the box. *
Maximum of 3 characters. Currently Used: 0 characters.
Company Title *

Please type your Full Company title
Signature of Acceptance *

Please type your Full Name
Do Not Fill This Out