Institutional Application

If you are a Government/Education/Military institution and would like to receive special institutional and/or quantity pricing for your institutional needs, please fill out this online application and fax a copy of your supporting document to (949)380-0888. One of our account managers will contact you as soon as we received all the required information and documentation.

*This application must be completed in full. Incomplete applications will be rejected. Completion of this application does not imply that you have been qualified for institutional pricing.

Institution Information:

Institution Name:	*
Contact Name:	*
Tax Exemption Status:
Tax Exemption Number:
Street Address:	*
City:	*
State:	*
Zip Code:	*
Country:	*
Tel #:	*
Fax #:
E-mail:	*
Website:
AP Contact:
AP Number:
Project Details:
Project ID/Name:
Product Required Date:
Projected Initial Delivery:
Projected Project Quantity:
Monitor Size:
Touchscreen Required
If Yes, Capacitive or Resistive:

Required VIDEO Inputs (Select all that apply):

	VGA (15 Pin D-Sub)		DVI		HDMI		Display Port
	Water Proof/Splash Proof		USB		RCA Composite Video

Power Requirement:
Operating Temp Range:
Storage Temp Range:
Panel Brightness Minimum:

Required Accessories:

AC Adaptor

Country:

Remote Control

Vehicle Power Supply

Mount/Stand

Description:

Describe usage purpose and environment:

Image verification

Type the characters you see in the picture:

*