Panaboard VAR Enrollment Form

Full and Complete Legal Company Name:

required fields in bold

Contact First Name:

Contact Last Name:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Country:

United States (Panasonic USA can only answer questions for USA customers. International visitors, please click here to find information for your country website.)

Phone Number:

Contact Email Address:

VAR Website:

Panaboard Sales of 2008:

Panaboard Sales of 2009:

Number of Sales Representatives:

Primary Marketing Contact:

Sales Contact:

Preferred Distributor**:

**Please select only one Preferred Distributor. You may change you Preferred Distributor as long as you notify the PCCNA scanner rebate administrator in writing before the close of the current quarter. If PCCNA receives no written notification of a change in your Preferred Distributor, your Preferred Distributor will remain the same. To change your Preferred Distributor you must submit a new form stating your changes.

Preferred Distributor Account #:

Type of Business*:

VAR
Service Provider
Systems Integrator

Percentage of Business (values must add up to 100)*:

%Government
%K-12
%Higher Education
%Other

Please list the Manufacturer(s) of the following products you currently sell:

Electronic Whiteboards:

Related Software:

Multifunctional (MFP) Devices:

Imaging Software:

Do you hold any state, local, educational, or federal contracts? (Examples, GSA, GWAC, MAC, BPA, IPIQ):

Who are your major competitors:

Please select a privacy option:

YES, I would like to receive information from Panasonic about special offers, promotions and new products.
YES, I would like to receive information from Panasonic and selected affiliates about special offers, promotions and new products.
NO, I would not like to receive information from Panasonic about special offers, promotions or new products.

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.

I AGREE TO THE TERMS AND CONDITIONS

Support

Business

Home & Business Communications

Document Management & Imaging

Retail Information Systems

Surveillance Monitoring/Video Imaging

Home & Business Communications

Become A Dealer - Panaboard VAR Enrollment Form