End User Deal Registration Form

Reseller Information

*Required fields

* Reseller Name:

* First Name (Sales Person):

* Last Name (Sales Person):

* Address:

* City:

* Country:

* State/Province:

* Zip Code:

* Phone:
( ) -

Extension:

* Email:

Distributor:
D&H
Ingram Micro
Synnex
Tech Data

* Company Name:

Primary Contact:

Primary Contact Title:

Email:

Address:

City:

Country:

State/Province:

* Zip Code:

Phone:
( ) -

Extension:

Summary of Reseller
History with Account:

* Estimated Close Date:
(mm/dd/yyyy)

* Est. $ Value of Configuration:

$1 - $4,999
$5,000 - $10,000
$10,001 - $15,000
$15,001 - $20,000
$20,001 +

Description of competitive
environment in the account:

Description of solution
being proposed:

Alternate solutions being
considered by the customer:

* Select the products and quantities:

Additional Notes: