Section 1
Company Name __________________________________________________________________________
Company Contact __________________________________ Title ______________________________
Business Address ______________________________________________________________________
City, State, Zip ______________________________________________________________________
Phone ________________________ Fax _______________________ State ________ Zip _________
Number of Locations ___ Business Type: __ Corporation __ Partnership __ Sole Proprietor
Years in Business ________  Number of Employees _________ 
Number of RCDDs   ________  Number of RCDD/LAN Specialists _________
Does your company have:  General liability coverage? ___ Yes ___ No  
Professional Liability error & omission insurance?   ___ 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 _________
4. ______________________________________ Date _____________ No. of Employees _________
5. ______________________________________ Date _____________ No. of Employees _________

Completed certification programs (manufacturers or Association (PLEASE LIST):
1. ______________________________________ Date _____________ No. of Employees _________
2. ______________________________________ Date _____________ No. of Employees _________
3. ______________________________________ Date _____________ No. of Employees _________
4. ______________________________________ Date _____________ No. of Employees _________
5. ______________________________________ Date _____________ No. of Employees _________

Section 3
A. What is the primary focus of your firm?
   ___ Telecommunications Consulting       ___ Architectural Engineering
   ___ Electrical Engineering              ___ Mechanical Engineering
   ___ Facility Planning                   ___ System Integration
   ___ Other (please list) ____________________________________________________________

B. What percentage of your firm's business is derived from structured cabling/cabling 
   systems (SCS) business?
   ___ 10%   ___ 25%   ___ 50%   ___ Over 50%

C. Does your firm write bid specifications for SCS projects?  ___ Yes  ___ No
D. About how many bid specifications for SCS projects did your firm write in 1997? 
   ___ 10    ___ 25    ___ 50    ___ Over 50

E. Which professional associations does your firm belong to? ____________________________

Section 4  Design/Specification References:
Firm ____________________________________ Contact ______________________ Phone # _________
Firm ____________________________________ Contact ______________________ Phone # _________
Firm ____________________________________ Contact ______________________ Phone # _________


All appliant information is confidential.
Please fax your completed application to 703-796-3626. If you have any questions
about the Field Verification Partner program, call Dennis Mazaris at 703-796-5526.