Machine Installation Customer Detail Form General Information: Company Name (required) Installation Address (required) Installation City (required) Installation State/Province (required) Installation Postal Code (required) Installation Country (required) Region (required) ---United StatesCanadaMexicoSouth AmericaChina & N. AsiaSoutheast AsiaEuropeMiddle EastAfrica Machine Equipment Number(s) being Installed. Provide for all machines being installed. (required) Machine Equipment Number(s) Previously Installed & Active. Please provide existing and active equipment numbers to update our records. Primary Manufacturing Management Contact: First Name (required) Last Name (required) Position/Title (required) Email (required) Phone Number (required) Primary Manufacturing Operations/Engineering Contact: First Name (required) Last Name (required) Position/Title (required) Email (required) Phone Number (required) Primary Parts/Service Purchasing Contact: First Name (required) Last Name (required) Position/Title (required) Email (required) Phone Number (required) Customer Attributes: Customer Classification ---OEMContract Manufacturer Primary Industry ---AutomotiveComputer SystemsComputer PeripheralsIndustrialLED LightingMedicalTelecom InfrastructureMilitary/GovernmentMobileSemi-ConductorOther Primary Universal Product (Please select a general UIC product category, particular to this customer facility) ---IMSMAutomationAPASGSMHSPAdvantisGenesisFuzionRadialAxialJumper Wire Secondary Universal Product (Please select a general UIC product category, particular to this customer facility) ---IMSMAutomationAPASGSMHSPAdvantisGenesisFuzionRadialAxialJumper Wire Primary Competitor Equipment (What other competitor equipment is currently installed at this facility, relative to the UIC equipment being installed) ---ASMEuroplacerFujiHitachiJukiMyDataPanasonicSamsungYamaha Secondary Competitor Equipment (If applicable) ---ASMEuroplacerFujiHitachiJukiMyDataPanasonicSamsungYamaha Form Submitter (Please provide your first and last name, in case we have questions about your submittal) (required) Submitter Email (Please provide your UIC email address) (required) Please Type the Code in the Box Below: