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Channel Partner Registration

Company Name:*
Primary Point of Contact:
Last Name:*
First Name:*
Telephone:*	--
Mobile Telephone:	--
Facsimile:	--
Email:*
Company Billing Information:
Billing Address 1:*
Billing Address 2:
City:*
State:*	[Select State] AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming --Canadian Provinces-- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Zip:*
Secondary Point of Contact Information:
Please provide the Secondary Point of Contact if different from Primary Point of Contact. Otherwise leave blank.
Last Name:
First Name:
Telephone:	--
Mobile Telephone:	--
Facsimile:	--
Email:
Number of Sales Representatives:*
Number of Customer Service Representatives:*
Customer Service (help desk) Hours:*	5days x 8hours 5days x 12hours 5days x 18hours 5days x 24hours 7days x 8hours 7days x 12hours 7days x 18hours 7days x 24hours
Number of Field Technicians:*
	* I agree with the Channel Partner Agreement

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