Dealer Registration Form

Oppotunity Name

Opportunity Location (State or Province)

Brief Description of Opportunity (200 Characters)

Registration Submittal Date

Date products are needed for customer delivery?

Date order is expected to be placed?

Have products been identified yet? Have products been identified yet? Yes No

Has a quote been generated yet by Dicolor? Has a quote been generated yet by Dicolor? Yes No

Does your team need assistance with configuring this solution with a Dicolor LED solution? Does your team need assistance with configuring this solution with a Dicolor LED solution? Yes No

Has an official RFP been issued for this opportunity?

If yes, when is this RFP due?

Does your company intend on bidding only Dicolor LED related products and services for requested items? Does your company intend on bidding only Dicolor LED related products and services for requested items? Yes No

If not, what other solutions are you bidding?

Are you aware of competitive products your customer is already using for these purposes? Are you aware of competitive products your customer is already using for these purposes? Yes No

If so, please provide any details on manufacture and/or model(s) currently being used and/or considered by this customer:

Company Name

Contact Name

Title

First Name

Last Name

Email Address

Billing Street Address

City

State/Province

Zip/Postal Code

Website

Phone Number

Primary Industry Focus (check all that apply) Primary Industry Focus (check all that apply) Education, Higher Education and/or K-12 Government, State, Local and/or Federal Healthcare All Segments DOOH and Marketing Film and Entertainment and AV Production Touring and Rental Industry Religious/House of Worship Other

Partner Type Partner Type Dicolor Authorized Dealer - Silver Dicolor Authorized Dealer - Gold Dicolor Authorized Dealer - Platinum New Partner

Company role regarding this opportunity: (check all that apply) Company role regarding this opportunity: (check all that apply) Consultant Referral Partner Integrator Partner Value Added Reseller Distribution Partner Services Partner