NVT Distributor Project Registration Request Form

Questions about Project registration? Please call 1-800-959-9870.

(* denotes required field)

 
Project Name: *
End User Company: *
Contact Name: *
Contact Phone: *

Additional Contacts:
Company: Contact Type:
     
Name: Phone:
     

  Distributor Information  
  Company Name:
*
  
  Full Address (Street, City, State, Zip):
*
  
  Salesperson:
*
  
  Email Address:
*
  
  Phone #:                                             Fax #:
*       *
  

Scope of project: (# of cameras, typical distances, etc.)*

Start Date (approx.):  / / *
End Date (approx.):  / / *




Please enter quantities for the specified products:
Qty ModelDescription
NV-208A-M Passive Video Transceiver
NV-214A-M Passive Video Transceiver
NV-653T Active Video Transmitter
NV-652R Active Video Receiver
NV-413A Passive Video Transceiver, 4 Channel
NV-452R Active Receiver Receiver, 4 Channel
NV-813 Passive Transceiver Hub, 8-Channel
NV-813S Passive Transceiver Hub, 8-Channel
NV-862 Active Receiver Hub, 8-Channel
NV-872 Digital EQ Active Receiver Hub, 8-channel
NV-1613 Passive Transceiver Hub, 16-Channel
NV-1613S Passive Transceiver Hub, 16-channel
NV-1662 Active Receiver Hub, 16-Channel
NV-1672 Digital EQ Active Receiver, 16-channel
NV-3213 Passive Transceiver Hub, 32-Channel
NV-3213S Passive Transceiver Hub, 32-channel
NV-3262 Active Receiver Hub, 32-Channel
NV-3272 Digital EQ Active Receiver, 32-channel
NV-216A-PV Power - Video Transceiver
NV-218A-PVD Power-Video-Data Transceiver
NV-226J-PV Power-Video Transceiver w/ 12VDC Converter
NV-704J-PVD Power-Video-Data Cable Integrator, 4-Channel
NV-716J-PVD Power-Video-Data Cable Integrator, 16-Channel
NV-8PS13-PVD Passive Receiver / Power Supply / Cable Integrator Hub
NV-16PS13-PVD Passive Receiver / Power Supply / Cable Integrator Hub
NV-4PS10-PVD Power Supply Cable Integrator Hub, 4-channel
NV-16PS10-PVD Power Supply Cable Integrator Hub, 16 Channel
RM 8/10 Rack Mount Panel

Distributor has agreed to register the project with NVT only: Yes
 
An NVT representative has met with end user: Yes
If yes, Meeting Date: / /
NVT Rep. Met with:

If desired, please add any additional remarks or comments:

All information on this form is strictly confidential and will only be shared with employees of the company submitting this document.

Note: This document must be submitted at least one month prior to NVT's receipt of a purchase order.