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First Name: *

Last Name: *

E-Mail Address: *

Company: *

Legal Company Name:

Website URL:

Address, City, State, Zip Code:

Country:

State of Incorporation:

Type of business entity:

How were you referred to AccessChannel?:

Is this a reseller specific request (click yes or no):

Yes
No

If yes, please provide name:

Public Company Stock Symbol:

Number of employees: *

Year Established: *

Is your company currently or has it ever been party to a lawsuit with a customer?:

Fiscal Year-end (month)?:

What percentage of your revenue is from United States(U.S.):

Total Annual Revenue: *

Annual Revenue (Channel Products): *

Projected rev. this year (All Products): *

Proj. rev. this year (Channel Products): *

Additional Contact Information

Salutation:

Title:

Phone: *

Fax:

Mobile Phone:

Channel Information

Percentage of sales to End Users:

Percentage of sales to Resellers: *

Percentage of sales to Distributors: *

Number of Resellers:

Will you be transitioning resellers to Ingram Micro:

If yes, how many:

Number of U.S. Channel Resources:

Number of U.S. Field Sales Reps:

Number of U.S. Inside Sales Reps:

Number of U.S. Technicians/SEs:

Current Distributors:

Total number of units shipped annually(units sold and returns):

Product Information

Select the Sub-Categories which best describe your products (check all that apply):

AIDC/POS
Business Software
Cabling
Components
Consumer Electronics
Consumer Software
Document Management
Gaming
Home Control
Mass Storage
Mobility
Networking
Network Storage
Presentations
Printers and Office Products
Security
Supplies and Accessories
Systems
Training and Services
Other

Brief description of product/services: *

Average Product MSRP: $ *

Average product price to distributor: $

Average Distributor Margin:

Reseller Certification Required:

Reseller Certification Offered:

Reseller Authorization Required:

Reseller Authorization Offered:

Customer Information

Types of Indirect Customer/Channels sold into (check all that apply):

Direct Marketer
VAR/Solution Provider
Corporate Reseller
Service Providers/Telcos
Retail
Other

Types of vertical markets sold into (check all that apply):

Healthcare
Financial
SMB
Government Education
Enterprise
Other

Key Technical/Business Partners:

List your key resellers/customers:

Competitors:

Key competitive advantages:

Marketing Information

What is your marketing budget for this Year? $ *

Demand Generation:

Targeted Reseller Market Segments (Check all that apply):

A/V Dealers
Commercial VAR
Corporate Resellers
Direct Marketer
Distributors E-Commerce
Education VAR
Governtment VAR
Retail
System Integrators
Other

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