Thank you for your interest in attending IT ChannelVision: Government Edition. We ask that you complete and submit the following Event Interest Form. After reviewing your submitted form we will contact you with a response and/or confirmation.

• Required Information
•Contact Name:
•Contact Title:
•Sender E-mail:
•Telephone:
•Fax:
•Company Name:
•Corporate Address 1:
•Corporate Address 2:
•City:
•State:
•Zip/Postal Code:
•Company URL:
•Indicate your primary business focus:	Select One IT Consultant Systems Integrator Total Solution Provider Reseller Distributor Other
Other:
•To what degree are you responsible for building the vendor partnerships and alliances for your company:	Select One Total Responsibility Partial Responsibility Minor Responsibility No Responsibility
•Does your company have a practice area/division focused on the government sector?	YesNo
•Are you part of this practice area?	YesNo
•What is your company's total annual revenue?	Select One <1M $1-4M $5-10M $11-25M $26-50M $51-100M $101-300M $301-500M $501M-1B >$1B
•What percentage of this total revenue was from business in the federal sector?	Select One 0% 1-10% 11-25% 26-50% 51-75% 76-100%
•What percentage of this total revenue was from business in the state & local government?	Select One 0% 1-10% 11-25% 26-50% 51-75% 76-100%
•What percentage of this total revenue was from corporate business?	Select One 0% 1-10% 11-25% 26-50% 51-75% 76-100%
•What percentage of your business is done directly with the federal government (prime)?	Select One 0% 1-10% 11-25% 26-50% 51-75% 76-100%
•What percentage of your federal business is through channel partners (subcontractor)?	Select One 0% 1-10% 11-25% 26-50% 51-75% 76-100%
Other:
•What percentage of your total revenue comes from the following areas (must total 100%)?
	Hardware % Software % Services % Total %
•Please select your boardroom category interest:
First Preference:	Select One Business Intelligence/Security Department of Defense Enterprise Applications Homeland Security Network Solutions State & Local Gov
Second Preference:	Select One Business Intelligence/Security Department of Defense Enterprise Applications Homeland Security Network Solutions State & Local Gov
Third Preference:	Select One Business Intelligence/Security Department of Defense Enterprise Applications Homeland Security Network Solutions State & Local Gov
•Is your company on a GWAC?	YesNo
•What percentage of your company revenue is generated from the following agencies? (Total = 100%) If the following categories are not applicable, type 0%.
Federal: Department of Agriculture: % Department of Interior: % Department of Commerce: % Department of Defense: % Department of Labor: % Department of Education: % Department of State: % Department of Energy: % Department of Transportation: % Department of Health & Human Services: % Department of Homeland Security: % Department of Veterans Affairs: % Department of Housing & Urban Development: % Environmental Protection Agency: % : % Total: % State & Local Government: Administration & Finance (Includes Revenue/Tax): % Health: % Human Services: % Transportation: % Public Safety: % Criminal Justice: % Public Works: % Natural Resources: % : % Total: %
Which, if any, SBA certification do you hold?	Select One HUBZone Veteran minority-owned business SDB/8(a) None Other
Other:
•Please indidicate your interest in seeing the vendors listed below at the event.     AMD High Medium Low Cisco High Medium Low Citrix High Medium Low Dell High Medium Low EMC High Medium Low Fujitsu High Medium Low Hewlett Packard High Medium Low IBM High Medium Low Intel High Medium Low Lenovo High Medium Low Panasonic High Medium Low Red Hat High Medium Low RSA High Medium Low Samsung High Medium Low SAP High Medium Low Sony High Medium Low Sun Microsystems High Medium Low Toshiba High Medium Low Trend Micro High Medium Low VMWare High Medium Low
•Please list 3 vendors you would like to see that were not included in the above list:
• How did you hear about our site?	Select one... Advertisement Brochure Editorial E-mail Fax Gartner Client Gartner Web Site Governing.com GovExecutive.com Postcard Press Releases Previous Attendee Referral Sales Associate Other Web site Other