Company Name:*
Primary Contact Name:*
Primary Contact E-Mail:*
Address:*
City:*
State:*
Select one...
CANADA
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DISTRICT OF COLUMBIA
DELAWARE
FLORIDA
GEORGIA
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
Zip Code:*
Phone Number:*
Fax Number:*
Does your firm have more than one location?*
Select one...
Yes
No
How many sales people are at this location?*
Sales Manager Name:*
Sales Manager E-Mail:*
Sales Manager Phone Number:*
Product Manager Name:*
Product Manager E-Mail:*
Product Manager Phone Number:*
Purchasing Contact Name:*
Purchase Contact E-Mail:*
Purchase Contact Phone Number:*
Technical Contact Name:*
Technical Contact E-Mail:*
Technical Contact Phone Number:*
Statement of Ownership:*
Select one...
Limited Partnership
General Partnership
Sole Proprietary
Corportation
Date Incorporated: (mm/dd/yyyy)*
State of Incorporation:*
Select one...
CANADA
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DISTRICT OF COLUMBIA
DELAWARE
FLORIDA
GEORGIA
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
Reseller ID#:*
(Note: You may be asked to provide a faxed copy of your reseller certificate upon
enrollment in the D-Link Premier Reseller Program.)
Primary Distributor:*
Primary Distributor Account #:*
Secondary Distributor:
Secondary Distributor Account #:
Do you offer on-site customer support?*
Select one...
Yes
No
Which vertical markets do you specialize in?
In miles, what is the radius that you will do installations?
Preferred Installation Size?
Select one...
0 - 25
25 - 50
51 - 99
100+
Which LAN hardware products do you sell?
Select one...
Wireless
10/100 Switches
Adapters
Gigabit
Contact Administrator