Partner Deal Registration Form

Please provide Secure Cyber Defense with the following information. The information obtained will be used to properly start talking and ultimately scope and quote services for your end customer. If you have any questions, please consult with Sales or contact Secure Cyber Defense at 937.388.4405, or

Partner Information

Partner Name(Required)
Partner Contact Name(Required)
Primary Address

End-Customer Information

End-User Customer Name
End-Customer Contact Name
If multiple, provide the city, state and zip for each location.
If multiple locations, specify number of users per location.
Solutions of Interest (checkboxes):
Please provide any additional information on solutions of interest.
Budget Quarter
This field is for validation purposes and should be left unchanged.