Section 1: Company Data

Company Name:
Main Contact Name:
Title:
Address:
Address (Cont.):
City:
State:	--Select One-- or
Zip Code/Postal Code:
Phone:
Fax:
Email:
Company Website:
Date Established:
Private	Public
	If not a school, please provide symbol:

Total number of Customers Worldwide:
Total number of Employees Worldwide:

Please provide the following information in US dollars.
Gross revenue for most recent fiscal year:
Gross revenue for previous fiscal year:

Are you an existing customer?

Yes     No

Section 2: Company Description

Please provide a brief overview of your company and products/services, including any activities related to online learning.

Section 3: Business Environment

Describe your company's positioning in its primary market(in terms of price, quality, differentiating factors, competition, etc.):

Describe your key business relationships (alliances and clients):

Section 4: Proposed Relationship

Please describe the type of relationship you envision with Blackboard.

Please check each product or service that applies to your company.
Software Publisher Reseller Security/Door Access Hardware		Content Developer Point of Sale Services Provider/System Integrator Other

Please check each market that applies to your company.
Higher Education Government Corporate		Primary/Secondary Education Association

Section 5: Miscellaneous

If applicable, describe any existing relationships or contacts you have at Blackboard, or provide any other information that is relevent in evaluating a potential partnership between Blackboard and your organization.