First Name
Last Name
Company
Email
Address 1
Address 2
City
State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew orkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip / Postal Code
Customer Support Email
Website
Phone
Primary Business Type Telephone SystemsMuti-Tenant Cable SystemsProperty Management Solution ProviderIT Managed Service ProviderVARInternet Service ProviderOther (Specify)
Specify Primary Business (If "Other")
How many MDU/MTU properties do you currently provide services to? None1-56-1011-2526-5051-7576-100101+
Year Business Established
Number of Employees
Annual Sales Under 500k501k-1M1M-1.5M1.5M-2.5M2.5M+
How did you hear about us? Online AdvertisementEmail/NewsletterReferral from another PartnerReferral from Property Owner/ManagerASCII EventChannelPro EventSearch EngineSocial Media (FB/Twitter/Other)MagazineTV/Cable NewsOther WebsiteOther (Specify)
Specify Referral Source (If "Other")
Any additional notes or questions?
By checking the box below you understand and agree that you are requesting to signup as an Aditum Channel Partner which will give you access to Partner Only resources and information, technical training, and other related services. If approved you will be authorized to use the Aditum Partner Badge provided to you within the IMS portal appropriate to your partner program level on all of your marketing and promotional material, provided it is in an unmodified state and used in a non-derogatory manor. You understand that you may receive documents and information that are Aditum Confidential for Channel Partner use only, and that you agree not to disclose any confidential partner information received. You also agree that your information may be used for direct marketing purposes by Aditum as well as joint marketing with companies which Aditum is partnered with. Aditum will not sell the or provide the information you provide to any 3rd party for any other purpose. I Agree
