For Office Use Only:  Certification #: __________  Date Issued: ______________

 Certified Contractor Application

Section 1
Company Name _____________________________________________________________________
Company Contact _____________________________ Title ______________________________
Business Address _________________________________________________________________
City _________________________________________________________________
Phone ______________________ Fax _______________________ State ______ Zip ________
Number of Locations ___ Business Type: __ Corporation __ Partnership __ Sole Proprietor
Years in Business ________  Number of Employees ______ Number of Technicians______
Does your company have:  General liability coverage? ___ Yes ___ No  
Is your company bonded?    ___ Yes ___ No

Section 2
Please list any completed technical training.
1. _____________________________________ Date ___________ No. of Employees _______

2. _____________________________________ Date ___________ No. of Employees _______

3. _____________________________________ Date ___________ No. of Employees _______

Completed certification programs (manufacturers or Associations (PLEASE LIST):
1. _____________________________________ Date ___________ No. of Employees _______

2. _____________________________________ Date ___________ No. of Employees _______

3. _____________________________________ Date ___________ No. of Employees _______

Section 3
General Information
No. of Installations/year ____  No. of years as an Installation Contractor ____
Preferred Horizontal & Backbone Cabling Systems Manufacturers (if any) ___________
Preferred Tester Manufacturer ____________________________________________________
     Do you own or rent your tester? ___ Own  ___ Rent
List local premise wiring distributor that you or your company regularly buys from:
NAME _______________________________________CITY__________________STATE___________
NAME _______________________________________CITY__________________STATE___________
NAME _______________________________________CITY__________________STATE___________

Section 4
How did you learn about the PerfectPatch? ________________________________________
Have you used the PerfectPatch at a customer site? ___ Yes   ___ No
What percentage of your jobs exceed 100 drops? _____%
Estimated number of jobs you have corrected patch-cord management systems: _____
You firm is classified as: ___ Local ___ Regional ___ National ___ International

What trade magazines do you subscribe to? ___ Cabling Installation & Maintenance
___ Cabling Business  ___ Teleconnect  __ Electrical Contractor  
___ Structured Cabling & Connecting Systems ___ Communications News ___ Other

Terms and Conditions
PerfectPatch, Inc. Certified Contractor
By submitting this application, PerfectPatch, Inc. Certified Contractor 
warrants that the contractor has all applicable licenses to perform the 
required work, has been trained in telecom installations to understand 
and comply with all codes and regulations, has a financially sound 
business with no threat of insolvency, and has general liability, to 
the satisfaction of PerfectPatch. Upon acceptance as a PerfectPatch, Inc. 
Certified contractor, the contractor (1) agrees to respond to all 
PerfectPatch, Inc. end user problems within 48 hours, (2) agrees to 
provide PerfectPatch, Inc. end-users with priority service, (3) guarantees 
that the prices charged to PerfectPatch, inc. end-users are no higher
than prices charged to any other customer for comparable services 
and goods, and(4) agrees to provide PerfectPatch, Inc. information 
regarding customer needs, product improvement and other suggestions 
for improvement. PerfectPatch, Inc. Certified Contractor agrees to 
take all steps necessary to effectuate its agreements and warranties 
to PerfectPatch, Inc.

      ______________________________________        ___________________________
                     Signature                                 Date

Please fax this application to 703-796-3626.