Prospective Strategic Reseller Application Form

Thank you for your interest in eClinicalWorks! Please fill out the Strategic Partner form below and submit it to eClinicalWorks.


Company Profile and Contacts
Company Name:*
Primary Address:*
City:*
State:*
Zip Code:*
Phone:*
Fax:
Email:*
Website Address:

Primary Contact
Name:*
Title:*
Phone:*
Email:*
 

Value of Partnership
Please give a brief description of what services your company provides.
*
What type of partnership would you like with eClinicalWorks?
(Reseller, Referral Partner, Product Integration, IT Reference, etc.)
*
Who is your target market and customer base? What territories do you cover?
*
What will this partnership bring to eClinicalWorks?
*
 

IT Reference

Please fill out only if interested in becoming an IT reference
If you have installed, supported or currently support a network and/or provided and installed hardware
for an eClinicalWorks client and you wish to be a client reference, please fill out this section. If not,
please skip to the next section

 

Please provide us with 2 customer references of eClinicalWorks clients you have worked with.

(Reference 1)
Practice Name:
Name of Lead Physician:
Office Manager or Other Contact:
Phone:
Email:
When did you begin working with this client?:

  

(Reference 2)
Practice Name:
Name of Lead Physician:
Office Manager or Other Contact:
Phone:
Email:
When did you begin working with this client?:
 

General Company Information
Date Company Established:*
Number of Sales Reps:*
Total Number of Employees:*
Revenue:*
Your Top 3 Competitors:
Do you work/partner with other EMR/PM Corporations? If so please mention their names:
*