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DEALER APPLICATION FORM

1. COMPANY/ADDRESS INFORMATION (*) Company Date Established January February March April May June July August September October November December ,  (*) Address 1 Address 2 Suite (*) City County State/Province Other (Non U.S.)AlabamaAlaskaAlbertaAmerican SamoaArmed Forces Americas (except Canada)Armed Forces Eur., Mid. East, Africa, CanadaArmed Forces PacificArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNorthern Mariana IslandsNebraskaNevadaNew BrunswickNewfoundland and LabradorNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsNorthern TerritoriesNo StateNunavitOhioOklahomaOntarioOregonPalauPennsylvaniaPrince Edward IslandPuerto RicoQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory Other State/Province Zip Code (*) Country (other)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatia (local name: Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHoly see (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, occupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States minor outlying islandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe Other Country (*) Phone Fax (*) Email Website Owner(s) Partner(s) Director(s) Main Contact(s) No. of Employees Sales Personnel Technicians Support Administration Capital (2008) Sales (2007) Sales (2008) 2. TYPE OF BUSINESS / CLIENT Distributor Installer End User Integrator Dealer Other(s) 3. PRODUCT LINE Complete Product Line Security Cameras Network Cameras TVs & Monitors Access Control DVRs (Digital Video Recorders) Megaphones Lenses Tools Antennas P.A. Amplifiers P.A. Speakers Power Supply Rotation Bases & Controllers Surge Protection Devices Twisted Pair Transmission Data Transmission Multimedia Transmission IP Cabling Transmission Metal Detectors Coaxial Cabling System Video Servers Wireless Receivers Wireless Transmitters Accessories Guard Patrol Video Interference Solutions Memory Open Rack Frames & Enclosed Equipment Cabinets CATV Interface Video Processor Central Management Software Other(s) 4. SUBMIT INFORMATION

Memory Systems, Corp 10858 NW 27th Street Miami, Florida 33172 U.S.A. Tel: (305) 594-9326 Fax: (305) 594-9692 Web: www.memorysystems.net Email: sales@memorysystems.net