mōsbē™ Partnership Program Interest Form Thank you for your interest in the mōsbē™ Partnership Program. We invite you to provide us with an introduction to your business and your goals for forming a business partner relationship with BreakAway. Submission of this questionnaire does not automatically grant you authorization into the Partnership Program. Once we have received your submitted questionnaire, a representative will contact you. The information provided below will be kept confidential. All fields are required. Full Name: --None-- Mr. Ms. Mrs. Dr. Prof. Mr./Mrs.        First Name                       Last Name                                                    Jr., III, etc. Company/Organization Name (required): Job Title (required): Address (required): City/State/Zip (required):   City                                 State                                Zip Your E-mail Address (required): Phone Number (required): Are you currently a licensee of mōsbē software? (required): YesNo Please provide us with a general overview of your current business and tell us briefly how mōsbē fits into your organization's objectives and goals. (required): What is your primary market and/or technology focus? (required): How many professional sales staff do you have dedicated to your sales efforts? (required): What value-added services do you provide (data, training, hardware)? (required): Have you had any interaction with anyone else at BreakAway regarding a possible business partnership? If so, who? (required): Please provide information on your company's experience using mōsbē. (required): Thank you for your interest in the mōsbē Partnership Program. If you have additional questions about the program, please e-mail: sales@mosbe.com.