Conergy Dealer Qualification

This form is for Canada, United States & U.S. territories only. For international requests, please visit www.conergy.com.

Items marked with * are required.

Contact Information:
Salutation
*First Name
*Last Name
Suffix
*Title
*Company
*Address
*City
*State/Province
*Zip/Postal Code
*Country
*Email
Website
*Phone
Cell
Fax
Headquarters (City)
Headquarters (State)
Preferred Communication Channel:
*How did you hear about Conergy?
Please specify:

Information about your business:
*How would you classify your business?
If other, please specify:
What market segment / industry does your business serve? Select as many as applicable*
How many PV systems has your company installed to date?
Number of Employees
Date Business Established
*Are you working with other Solar Distributors?
Do you have business relationships (self, staff, contractor) with the following? Select as many as applicable*
What services from Conergy are you interested in?	Financing Training
*Does your company have projects to install within the next 90 days?
Anything else you want us to know?

[Data protection guarantee: The information given by you is under data protection. It shall be used by Conergy solely for the purpose of qualification. We will not trade, sell or distribute your information for any other purpose or use.]