Belden AVSS Integrator Incentive Program

WELCOME!

Welcome to the Belden AVSS Integrator Incentive Program. Successful completion of the following questions will put your enrollment in process. All information will be kept in strict confidence. Required fields are marked with an asterisk (*). Following completion of the program registration, the program administrator will contact you via email within 48 hours to provide confirmation, your account number, and any additional instructions.

* Required
Business Name *
Please use independent business name as advertised
 
Business Address 1 *
Address 2
 
City / Town / Province *
 
State *
 
Country *
 
Postal Code *
 
Business Phone Number *
 
Company Web site
 
How many locations does your company have?
 
Primary Contact - First Name *
Primary contact for participation in this program
 
Primary Contact - Last Name *
Primary contact for participation in this program
 
Primary Contact Title *
What is your position in the company
 
Primary Contact Email Address *
Email will be the primary form of communication for this program
 
Retype Primary Contact Email Address *
Please make sure this is accurate
 
Primary Contact Phone Number *
 
Secondary Contact Name
 
Secondary Contact Title
 
Secondary Contact Email Address
 
Secondary Contact Phone Number
 
How would you classify your business type? *
Select One
  • AV Integrator
  • System Integrator
  • Other:
 
What is the primary focus of your buisness
Select all that apply
  • AV Integration
  • System Integration
  • Access Control
  • CCTV
  • Network Systems
  • Fire
  • Lighting
  • Other:
 
What is the approximate annual sales revenue for your business?
Select One
 
How many employees do you have?
Select One
 
Approximately how much did you spend on connectivity purchases in 2010 *
Consider all purchases of cables, connectors, fiber, and racks
$ 
 
Considering all purchases of connectivity and routers, approximately what percent of your purchases were Belden branded products? *
Consider all purchases of cables, connectors, racks and routers
 
Where do you purchase the majority of your connectivity products? *
Choose one, considering purchases of cables, connectors, racks and routers
  • AccuTech
  • ADI
  • Allied Electronics
  • Anixter
  • Arrrow
  • BTX
  • Carlton Bates
  • CSC
  • Graybar
  • Genie
  • Herman
  • Houston Wire and Cable
  • Joseph's
  • Liberty
  • Newark
  • Omni
  • Pac Radio
  • Rexel
  • RS Electroncis
  • Windy City
  • Westlake
  • Wire Express
  • Other:
 
Where else do you purchase connectivity products? *
Select all that apply
  • Accutech
  • ADI
  • Allied Electronics
  • Anixter
  • Arrrow
  • BTX
  • Carlton Bates
  • CSC
  • Genie
  • Graybar
  • Herman
  • Houston Wire and Cable
  • Joseph's
  • Liberty
  • Newark
  • Omni
  • Pac Radio
  • Rexel
  • RS Electroncis
  • Westlake
  • Windy City
  • Wire Express
  • Other:
 
Do you currently participate in an another Belden program? *
Participants may be enrolled in only one Belden program
  • Yes
  • No
 
If you are enrolled in another Belden program, please describe that program below
 
I certify that, to the best of my knowledge, and in good faith, the information provided is accurate and was not done under false pretense to manipulate an outcome. *
  • I agree
  • I do not agree
 
I would like to receive a visit from a local Belden Consultant *
  • Yes
  • No
  • Other:
 
If you know your local Belden Consultant, please enter the name
 
Who informed you about this program?
    Name:
    Company:
    Other: