Siemon Registered Installer Application Form

Siemon Registered Installer Application

Please contact your Siemon representative if you are located outside of North America.
State/Province Sync
English Non NA

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SFDCID
SFCMPGN
CI Coordinator
Region*
Country*
Main/Authorized Contact*

First NameLast Name
Title*
Main/Authorized Contact Phone Number*

Area CodePhone Number
Main/Authorized Contact Email*
example@example.com
Company Name*
Company Street Address*
City*
US State
Province
Zip/Postal Code*
Mexico State
AU State
Main Phone Number

Area CodePhone Number
Website*
Does your company have multiple locations/branches?*
If yes, please list below

How many years has your company been in business?*
Total number of company employees*
Number of project managers developing bids, quotes, and/or SOWs involving cabling specifications*
Number of technicians/installers*
Please specify your company's geographic coverage area
(EX: Northern Indiana, Metro NYC, New Hampshire & Vermont, Etc.)
Please specify your company's main industry focus areas/expertise (select all that apply)*

Datacom / LANWiFiSecurity - Surveillance/Access ControlAudio/Video and Digital SignageMobile Wireless / DASPoE LightingBASElectricalOther
Does your company maintain partnerships or certifications with other cabling vendors?*
Please list the cabling vendors with which you maintain partnerships or certifications*
Does your company maintain partnerships or certifications with any device and/or system manufacturers in the following markets/applications? Please select all applicable areas and specify companies below.*

Datacom / LANWiFiSecurity - Surveillance/Access ControlAudio/Video and Digital SignageMobile Wireless / DASPoE LightingBASElectricalOther
DataCom/LAN manufacturer partners:
WiFi device/system manufacturer partners:
Security device/system manufacturer partners:
Audio/Video and/or Digital Signage device/system manufacturer partners:
Mobile Wireless/DAS device/system manufacturer partners:
PoE Lighting manufacturer partners:
BAS device/system manufacturer partners:
Electrical device/system manufacturer partners:
A/V Focus
IB Focus
Supply Channels: – List the distributors and locations from whom you prefer to purchase connecting hardware and cable.
Distributor 1*
(Company name, Branch Location)
Distributor 2
(Company name, Branch Location)
Distributor 3
(Company name, Branch Location)
Other purchasing channels
(Please specify)
Authorized Signature:
- By signing below, I confirm that I am an authorized representative of above listed company and that all information provided is accurate.
- Please note: This is an application. Registered Installer status is not valid until the application is approved in writing by Siemon and subsequent Registered Installer documentation and training requirements are met. Siemon reserves the right to determine applicant eligibility at its sole discretion.
- Upon submission and Siemon review of your application, a Siemon representative will contact you with next steps.
Authorized Representative Name

First NameLast Name
Authorized Representative Signature
Date

MonthDayYear
Date
Application F048 Online Form
Should be Empty:

Rows	Street Address	City	ST/Province	Branch Contact	Contact Email
Branch 1
Branch 2
Branch 3
Branch 4
Branch 5