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:
•Cell:
•Company Name:
•Corporate Address 1:
•Corporate Address 2:
•City:
•State:
•Zip/Postal Code:
•Company URL:
•Which of the following best describes your firm's primary and secondary business?
Primary Business (Select One) Secondary Business (Select All) Large/Enterprise Mid-Market Small Business Healthcare State/Local Education (VM) Federal
What percentage of your business is focused on the following areas? (must add up to 100%, please put 0% if it does not apply
: Network Infrastructure: % Security: % Storage: % System Integrator: % Managed Services: % Mobility: % Virtualization: % Cloud Computing/SAAS: % Other: % Total: %
•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
What is the number of employees in your entire organization? (including all divisions, branches and subsidiaries)
Select One 5000+ 1000-4999 100-999 20-99 10-19 5-9 < 5
•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 territory does your company cover?
Select One local regional national global
•What percentage of your total revenue comes from the following areas (must total 100%)?
Hardware % Software % Services % Total %
•Please select your category of interest:
First Preference:	Select One Collaboration (Web 2.0, Social Networking, Crowd Sourcing) Department of Defense Healthcare Security (physical, cyber) State & Local Sustainability (Cloud Computing, Green IT, Hosted Solutions, Networking)
Second Preference:	Select One Collaboration (Web 2.0, Social Networking, Crowd Sourcing) Department of Defense Healthcare Security (physical, cyber) State & Local Sustainability (Cloud Computing, Green IT, Hosted Solutions, Networking)
Third Preference:	Select One Collaboration (Web 2.0, Social Networking, Crowd Sourcing) Department of Defense Healthcare Security (physical, cyber) State & Local Sustainability (Cloud Computing, Green IT, Hosted Solutions, Networking)
•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:
•Which of the following partner programs does your company participate in? (Select all that apply.)
3COM IBM Sprint Adtran Intel Symantec Alcatel-Lucent Lexmark Sun Microsystems AMD McAfee Toshiba APC Microsoft Viewsonic BMC NEC Displays Websense Cisco Nortel Eaton/Powerware Citrix Novell Lenovo CA Oracle VMWare D-Link Red Hat Business Objects Dell Samsung Sage EMC Sonic Wall SAP HP/Compaq Sony Other
Please identify your organization's primary and secondary distribution partners:
Primary Distributor (Select One) Secondary Distributor (Select All) Arrow ASI Avnet/Hallmark Catalyst/Telecom CDW/CDWG Comstor D&H GE Access Ingram Micro Scan Source SED Synnex Tech Data Tessco Westcon Other
Please indicate which of the following social networks you belong to: (Check all that apply)
Face Book LinkedIN My Space Digg ChannelWeb Twitter Other
What is the total value of Hardware, Software, and Services that you will purchase this year from distribution, manufacturers, other Solution Providers, or any other source as elements to the solutions you will deliver to your clients?
Select One Over 500 Million $200 - $499.9 Million 100 - $199.9 Million $50 - $99.9 Million $20 - 49.9 Million $10 - 19.9 Million $5 - 9.9 Million $2 - 4.9 Million Under $2 Million
•Please list 3 vendors you would like to see that were not included in the above list:
1. 2. 3.
• 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