Xerox DTPM/SSP Application

	Privacy		Xerox Support

Important!
Please note:

After this form is completed, you will be taken to the online training order form. Ordering training is not a requirement of the Application Process, though it is highly recommended. Access to all Partner Information is only available to Partners with Certified Technicians, and training is required for all certifications.

Program benefits include:

Reimbursement for warranty and Xerox Service Agreement repairs
Genuine Xerox parts available at competitive discounts
Web-based and telephone technical back-up support for your technicians
Web-based parts ordering and warranty claim process
Dedicated Program Manager to ensure your business thrives in our program

Program criteria:

Minimum 1 service technician for each service location
Internet access / PC / Laptop

Service Provider Type	Annual Program Fee	Annual Documentation & training Fee				Additional Training Packages	Parts Discount
Service Provider Type	Annual Program Fee	1-5 techs	6-10 techs	11-20 techs	More than 20 techs	Additional Training Packages	Parts Discount
DTPM/SSP	$495	$265	$365	$565	$265 + $20 per tech over 5	$75	25%

* = required information

Company/Corporate Information

Organization Type*

Registered Reseller - If you are a registered reseller do not continue. Go to the Reseller website to apply to the ASP program at www.office.xerox.com/resellers
Designated Third Party Maintainer (DTPM) (Details)
Self Service Provider (SSP) (Details)

Legal Company Name*

Doing Business As (DBA)

Parent Corporation (if applicable)

Company Address *
Physical addresses only.
No PO boxes please.

Address Line 1

Address Line 2

City State/Province Zip/Postal Code

Enter more information
regarding this location *

Primary Billing Address
If different than Main
Company Address

Address Line 1

Address Line 2

City State/Province Zip/Postal Code

Primary Shipping Address
If different than Main
Company Address

Physical addresses only.
No PO boxes please.

Address Line 1

Address Line 2

City State/Province Zip/Postal Code

Primary Company Phone*

Primary Company Fax*

Primary Contact Name*

Primary Contact Email *

Additional Contacts

Position	Name	Email	Phone	Ext
Owner/General Manager*
Service Manager*

Service Location Information

Service Locations
Enter any additional service locations

Technician Information

Technician Details *
At least one Technician is required to be entered for your application to be approved

Additional Information

What customers will you be servicing*

Where did you learn about our Program?

What is your business size in terms of annual revenue?

Which of the following best describes your business focus?
Check all that apply.

Education	Professional Services
Health Care	Security
IT Support	System Integrator
Insurance	Other
Networking

Which of the following OEM products are you currently servicing?
Check all that apply.

Comments:

Please let us know any additional comments or information you may have;

Application Submission

I represent to Xerox that I have the authority to submit this Application on behalf of the Company identified above. By submitting this Application, Xerox is authorized to verify and of this information with third parties. Receipt of this Application by Xerox in no way constitutes acceptance into the Xerox Authorized Service Provider Program. Xerox will review the Application and at its sole discretion, may accept or reject the application. Once submitted to Xerox, this Application shall become the property of Xerox.

The annual program fees are as follows:

$495.00 Annual program Fee (Waived for Education Self Service Provider)
Documentation & Training Fee:
   $265 1-5 techs
   $365 6-10 techs
   $565 11-20 techs
   $265+$20 per tech over 5 (when more than 20 techs)

*You will be invoiced upon the receipt of a signed agreement

Xerox will be contacting you with additional details for payment of program fees. Verify your email address

Name*
Title*
Email Address*

I AM NOT A ROBOT

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