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Name:

Title or Position:

Company Name:

Address 1:

Address 2:

City:

State:

Country:

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Type of Business:

OEM

Distributor (If checked, please see question 13)

System Integrator

Other

If you are a Distributor, would you be interested in representing Amphenol Sine Systems products?

Yes

Industry Type:

Job Function:

Products of Interest:

Connector Products

PowerBOSS / ControlBOSS / PowerBOSSlite

Rockwell Motion Cables

Custom Applications

Are you currently using Rockwell Automation products?

Yes

If so which Series?

Would you like a Sales Representative to contact you?

Yes

Please check Yes or No if you would like to receive a FREE 512Mb USB Memory Stick.

Yes