Galaxy lead registration form

* Rep Name:

* Company name

* Your email

Your phone number

Bell Micro sales rep. name

* Company Name

* Dept-Division-Room Nº

* Address

* City

* State --Select a State/Prov.-- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Wash D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Isl. Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon ** Not in list **

* Zip

Country (leave blank if in USA) --Select a Country-- United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaidjan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canada Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland Former Czechoslovakia Former USSR France France (European Territory) French Guyana French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe (French) Guam (USA) Guatemala Guinea Guinea Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast (Cote D'Ivoire) Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique (French) Mauritania Mauritius Mayotte Mexico Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia (French) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Polynesia (French) Portugal Puerto Rico Qatar Reunion (French) Romania Russian Federation Rwanda S. Georgia & S. Sandwich Isls. Saint Helena Saint Kitts & Nevis Anguilla Saint Lucia Saint Pierre and Miquelon Saint Tome and Principe Saint Vincent & Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Tadjikistan Taiwan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zaire Zimbabwe ** Not in list **

* Primary contact

* Customer email

* Title

Secondary contact

Title

* Telephone number

Describe configuration requirements
(Be as specific as you can)

Estimated PO Timeframe:

1-30 Days 31-90 Days 91-120 Days 121+ Days 6+ Months

How did you promote Galaxy product(s) to end user?

In person Phone Email

Is this end-user an existing customer of yours…?

Yes No

if yes for how long…?

months years

I would like to schedule a conference call with a Bell Micro Account Manager and my customer once my registration is approved?

Yes No

Please have an engineer call me regarding this account for configurations?

Yes No