CounterIntuitive Software
Partner Application

* Mandatory Field

1. Company Information
      Please fill out the following company information

Company Name :	*
Street Address :	*
City :	*
State :	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  *
Zip/Postal Code :	*
Company URL :	*

2. Primary Contact
      Who is the primary person that we should contact regarding this partnership?

Full Name :	*
Title :
Telephone Number :	*
Fax Number :
Mobile Number :
Email Address :	*

3. Partner Type
      What type of partnership is best suited for your company?

Medallion :	Referrals Only
Gold Medallion :	Resell and implement CounterIntuitive products
Platinum Medallion :	Joint development of products

4. Territory Coverage
      Please answer the following questions(s) regarding your market coverage.

	A: Please describe your graphical target market
	B: Please describe your current customer base and their estimated employee size (specify the number of MSCRM installations) and future customer base:

5. Value Proposition
      Please answer the following question regarding your value proposition.

	A: Estimated number of customer companies and users you will sell or leverage for CounterIntuitive Software for the next 2 years?