- OEM Program Sign Up

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ACD OEM Program Sign Up

Instructions: All information must be complete.

General Company Information:

* Legal Entity (check one):

Corporation

Partnership

Proprietorship

* Name of Business

Contact Information:

* First Name

* Last Name

* Title

* Street Address 1

Street Address 2

* City, State, Zip

* Main Telephone Number

* Fax

* Email address

* Federal Tax ID#

Dun & Bradstreet Number

* D&B Rating

* Rating Date

* Line of Business

* Principals

* Number of Years in Business

Accounts Payable Contact Information:

* Name

* Email

* A/P Phone # including extension if applicable

* Products Manufactured

BANKING:

* Bank of Account:

* Street Address 1:

Street Address 2:

* City, State, Zip:

Bank Account Officer Contact:

* Name:

* Telephone:

PRINCIPAL TRADE SUPPLIERS- PLEASE PROVIDE 3 REFERENCES:

Name:

Street Address 1:

Street Address 2:

City, State, Zip:

Telephone:

Name:

Street Address 1:

Street Address 2:

City, State, Zip:

Telephone:

Name:

Street Address 1:

Street Address 2:

City, State, Zip:

Telephone:

Additional Locations:

Please include any additional sales and/or shipping locations below.

Address 1

Address 2

City, State, Zip

Contact

Phone

Address 1

Address 2

City, State, Zip

Contact

Phone

Contacts:

Please let us know the primary contact for Amphenol Cables on Demand.

* Name of Applicant:

* Company:

* Title:

* Email Address:

* Phone: