Application Date ________________________________________________________________________________
Company End User Name _________________________________________________________________________
Contact Name __________________________________________________________________________________
Address ______________________________________________________________________________________
City __________________________________________ State _____________ Zip __________________________
Telephone _______________________ Fax _____________________Other ________________________________
Approximate size of company _____________________________________________________________________
Other names in the organization interested in BeldenÆ products __________________________________________
_____________________________________________________________________________________________
Installation Contractor Name _______________________________________________________________________
Address ______________________________________________________________________________________
City __________________________________________ State _____________ Zip __________________________
Telephone _______________________ Fax ____________________ Other ________________________________
Project Manager Name _______________________________________________ Telephone __________________
RCDD certified? [  ] Yes  [  ]No    Are you a Belden Registered Installation Contractor? [  ] Yes  [  ] No
List all other certifications by name _________________________________________________________________
______________________________________________________________________________________________
Project Name __________________________________________________________________________________
Project Site Address ____________________________________________________________________________
State ______ Zip _______________ Other Contact Information___________________________________________
Project Start Date ________________________________ Project Completion Date ___________________________
Remote Site Location  [  ] Yes  [  ] No   Contact information _______________________________________________
Future Site Locations   [  ] Yes  [  ] No   Contact information ______________________________________________
Number of station locations for:  Voice _______________  Data _______________   Other _____________________
Connectivity manufacturer(s) and products used:  Fiber ________________________________________________
Copper _______________________________________________________________________________________
Are components compliant with all the intended applicatons? [  ] Yes   [   ] No
List all intended network protocol applications ________________________________________________________
Were TIA/EIA 568-A installation and testing procedures completed for all site locations? [   ] Yes   [  ] No
Do all the test results comply with TSB-67?  [  ] Yes  [  ] No
Was the ACR value at least 10.0dB for every node?  [  ] Yes   [   ] No
Test Equipment Manufacturer ________________________________  Model number _________________________
Network Hub Mnaufacturer _______________________________________________________________________
Belden Products Installed:    Copper _____________________________ Footage ____________________________
                                              Fiber ______________________________  Footage ____________________________
Distributor or reseller where you purchased Belden product _____________________________________________

By signing below, end user and installtion contractor certify that the above information is true, accurate and complete.  If this form is submitted electronically, then by filling in the names and dates below, the end user and the installation contractor - (1) certify that an original version of this form was manually signed by such persons on such dates, and (2) agree that such originally signed form will be given to Belden upon request.
End User Customer Signature ___________________________________________   Date _________________
Installation Contractor Signature _________________________________________   Date ________________
Belden Authorized Signature (Belden use only) ______________________________    Date _________________