Please note:
Fields marked with an asterisk
*
are required in order to update/complete and submit your record.
* Name:
* Address:
* City:
State/Province/County
* Postal Code:
* Telephone Number:
(
)
* Fax Number:
(
)
Primary Contact
* First Name:
* Last Name:
* Email:
* Title:
* Phone:
(
)
Ext:
* Fax:
(
)
Sales Manager Contact
First Name:
Last Name:
Email:
Title:
Phone:
(
)
Ext:
Fax:
(
)
Product Manager Contact
First Name:
Last Name:
Email:
Title:
Phone:
(
)
Ext:
Fax:
(
)
Purchasing Contact
First Name:
Last Name:
Email:
Title:
Phone:
(
)
Ext:
Fax:
(
)
Technical Contact
First Name:
Last Name:
Email:
Title:
Phone:
(
)
Ext:
Fax:
(
)
Please provide information on additional locations :
* 1.) Does your firm have more than one location?
Yes
No
* 2.) Are you currently an authorized reseller?
Yes
No
* 3.) How many sales / techs are at this location: Sales :
Techs :
* 4.) Statement of Ownership
(check all that apply)
?
Limited Partnership
General Partnership
Sole Proprietary
Corporation
* 5.) Date Incorporated :
* 6.) State of Corporation :
* 7.) Publicly Held?
Yes
No
* 8.) FEIN / SSN :
Who are your primary D-Link Distributors :
9.) Primary Source:
Rep Phone:
Ext:
Acc#:
10.) Second Source:
Rep Phone:
Ext:
Acc#:
11.) Third Source:
Rep Phone:
Ext:
Acc#:
Help D-Link to send you the appropriate leads :
* 12.) Do you offer on-site customer support :
* 13.) Which vertical market do you specialize in? :
* 14.) What is the radius that you will do installations? :
* 15.) Preferred Install sizes?
0-25
25-50
less than 100
100+
* 16.) Which LAN Hardware products do you sell?
Wireless :
10/100 Switches :
Adapters :
Gigabit :
Failure to claim the quarterly rebates may terminate my status as a Diamond Reseller.
I will contact all D-Link Leads within 48 hours of receipt.
I will support D-Link's efforts in my marketplace.
I Agree to the above terms and conditions
* First Name:
* Last Name:
* Email:
* Title:
* Phone:
(
)
Ext:
* UserID:
* Password: