Signamax Authorized Installer Information

    *Company Name: *Certificate Number:
    *Lead-Installer: *Certificate Number: *E-Mail:

    Cabling System End User Information

    *End User Name (As it would appear on the certificate):

    *Address 1: Address 2/Suite:
    *City: *State:
    Contact Name: Phone Number: E-Mail:


    *Cabling installation location same as the address provided above?


    Provide Install location (As it will appear on the certificate)

    *Project Name:

    *Address 1: Address 2/Suite:
    *City: *State:

    Cabling System Information

    *Twisted Pair Cabling (check that apply): Category 5eCategory 6Category 6A

    *Total Number of Copper Links: *Sample Configuration ID (Labeling Scheme) :

    & : Connecting Hardware

    *Select: Select: Select:

    : Work Area

    *Select Jack #1: Select Jack #2:

    : Horizontal Cable

    *Cable Manufacture: *Part Number:
    Cable Manufacture: Part Number:

    : Equipment Cable (if applicable)

    Select Equipment Cord (Patch Cable): Equipment Cord (Patch Cable):


    Additional Miscellaneous Materials:


    *Was fiber also installed?


    *Optical Fiber (check that apply): OM1OM3OM4OS1/2

    *Total Number of Fiber Links: *Sample Configuration ID (Labeling Scheme) :

    Provide installed cable and hardware:
    *Cable Manufacture: *Cable Part Number:
    Cable Manufacture: Cable Part Number:
    *Fiber Enclosure #1: *Fiber Adapter Plate #1: Pigtail #1: Fiber Connectors #1:
    Fiber Enclosure #2: Fiber Adapter Plate #2: Pigtail #2: Fiber Connectors #2:
    Additional Miscellaneous Materials:

    Attach Documentation

    Attach Test Results: Format: Fluke's .flw , Softing .prx files or .zip Floor Plan (if available): Format .pdf , jpg , .png, .zip Additional Supporting Doc: Format .pdf , jpg , .png, .zip

    Additional Comments:

    By sumitting this application, you agree to all the terms and condition set forth by Signamax, Inc in accordance with the Signamax Manual and Standards in effect at the time of installation. Project was installed by a Signamax Authorized Installer or Signamax Authorized Consultant using approved products.