First Name:
Last Name:
Title:
Company:
Address: (please no PO Boxes)
City:
State/Province: If you are outside the U.S.A. or Canada, please select 'Other'	Select... Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Other
Country:	U.S.A. Albania Algeria Argentina Aruba Australia Austria Bahamas Bahrain Bangladesh Belarus Belgium Brazil Bulgaria Camaroon Cambodia Canada Cayman Islands Chile China Colombia Costa Rica Croatia Cyprus Czech Republic Denmark Diego Garcia Dominican Republic Ecuador Egypt England Estonia Finland France Germany Great Britain Greece Guam Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Korea Kuwait Latvia Liberia Libya Lithuania Luxembourg Malaysia Malta Island Mauritis Mexico The Netherlands New Zealand Nigeria North Africa Norway Pakistan Panama Paraguay Peru Philippines Poland Portugal Puerto Rico Romania Russia Saudi Arabia Scotland Singapore Slovakia Slovenia South Africa Spain Sweden Switzerland Syria Taiwan Thailand Theale Tunisia Turkey United Arab Emirates Uganda Ukraine Uraguay Venezuela Vietnam West Indies Yugoslavia Zambia Zimbabwe
Zip/Postal Code:
Please fill in either USA/Canada OR International phone and fax fields:
US/Canada Phone:	1-
or International Phone:
US/Canada Fax:	1-
or International Fax:
e-mail:
Corporate URL:
There are important differences between Authorized and Select membership. Take a moment to review the benefits and requirements of each level and choose the level that's right for you.	Show me requirements and benefits of both
The level of membership I am interested in is: Authorized Level  Select Level (requires nomination by regional manager)
Key Executives and Company Contacts: Company contacts will be the designated primary person to receive NCD information
President/CEO/Owner:
Title:
e-mail:
phone:
Vice President:
Title:
e-mail:
phone:
Sales Contact
Title:
e-mail:
phone:
Marketing Contact:
Title:
e-mail:
phone:
Purchasing Contact:
Title:
e-mail:
phone:
Designate a Technical Support Contact only if you are applying for Select Level membership. You should designate someone within your organization who is authorized to contact NCD for technical support. If you are applying for Authorized level membership, you may skip this information.
Technical Contact:
Title:
e-mail:
phone:
Business Profile
Your company's business plan for promoting and selling thin-client technologies:
Which of the following reselling relationships do you currently support:
Bay Networks	Boundless
Cisco	Citrix
HP	Hummingbird
IBM	Neoware
Novell	Sun
WRQ	Wyse
Microsoft*	Other
*Enter your MCSP Number:
How do you characterize your value add?
Hardware	Software
Installation	Customization
Training	Consulting
Technical Support Services
What is your geographic coverage?
International  National  Regional
What markets and industries do you serve?
Automotive	Call Center
Customer Service	Enterprise
Financial Industries	Healthcare
Insurance	Internet
Kiosk	Manufacturing
NT	Retail
UNIX	Other
If your company listed on the GSA schedule, please provide your schedule number:
Is your company listed on any other Federal, State or local government buying vehicles?
Annual Sales (minimum $2 million)	$
% of sales from hardware
% software	% service

Which of the following companies do you purchase products from? Please list your customer number for all companies you do business with.

Thank you for completing this application for NCD's authorized reseller program. In submitting this, it is understood that this is an application and that approval to resell NCD products is subject to review and acceptance by NCD. Automatic acceptance into this program is neither expressed nor implied. All information given will be kept confidential. Either party may terminate this relationship at any time upon 30 days written notice.

If you are approved by NCD as a partner, you will receive a notification that will include your NCD authorization number and the URL to request a password to the NCD Diamond Partner Site.

We will reply to you within 5 - 7 business days with the appropriate next step in our process.