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Note: Fields with a * are required.
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| Company Name * (Full legal name required) |
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| Address * |
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| City * |
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| State * |
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| Telephone * |
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| Fax |
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| Management Contact Name * |
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| Management Email Address * |
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| Confirm Email Address * |
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| VAR Website |
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| Scanner Sales for 2008 |
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| Total Sales for Calendar 2008 (Incl.Service, Software, other hardware, etc.) * |
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| Projected Scanner Sales for 2009 |
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| Projected total sales for Calendar Year 2009 * |
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| Number of Sales Representatives |
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| Primary Marketing Contact |
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| Primary Sales Contact |
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| Type of Business * |
VAR
Service Provider
Systems Integrator
Service Bureau
ISV
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| Percentage of Business * (values must add up to 100) |
% Government
% Commercial
% State & Local
% Other
if other, please add the text
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| Markets * |
Accounting
Banking
Commercial
Data Capture
Document Management
Education
Federal Government
Healthcare
Insurance
Internet Based
Legal
Transportation
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Please list the Manufacturer(s) of the following products you currently sell:
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| Scanners |
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| Imaging Software |
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| Multifunctional (MFP) Devices |
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| Other Software * |
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Do you hold any state, local, educational, or federal contracts?
(Examples, GSA, GWAC, MAC, BPA, IPIQ):
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Who are your major competitors:
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Please select a privacy option *
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Terms and Conditions: *
The PIIV Program is offered exclusively to Imaging Value Added Resellers only. All other resellers, including Internet resellers, distributors and dealers, are excluded from the PIIV Program. PCCNA reserves the right to deny the application of or dismiss a VAR from the PIIV Program at any time for any reason. By executing this Program Enrollment Form, you agree to comply with the terms and conditions of the PIIV Program and consent to PCCNA sending you further details regarding the PIIV Program and other product information by facsimile, e-mail or other means. All of part of the PIIV Program may be changed or cancelled at any time without notice.
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