Name of the manufacturer to whom this registration is being submitted
Name of the person submitting the form
Email address of the person submitting the form
The date this form was presented to the manufacturer Date Format MMDDYYYY
Product Liability Concerns
Identify Yes or No if this product will be used in a life support or endangering application
The date the Mfg. or Rep and the distributor visit the customer. Date Format MMDDYYYY
Distributor Tracking Number
Tracking number assigned by the distributor to track this registration
Branch Location (City and State)
Location of the distributor branch City and State
Sales Person, Phone, Email
Distributor Account representative, phone, and Email
Distributor FAE, Phone, and Email
Internal distributor assigned account number for the customer
Country location of the customer
Mfg. Rep. or Sales Person
Applicable manufacturer’s representative assigned to the account with phone and Email. This can be the Rep firm if no individual is identified.
Applicable manufacturer’s responsible sales person with phone and Email
PURCHASING CUSTOMER INFORMATION
Internal distributor assigned account number for the customer
Country location of the customer
Mfg. Rep. or Sales Person
Applicable manufacturer’s representative assigned to the account with phone and Email. This can be the Rep firm if no individual is identified.
Applicable manufacturer’s responsible sales person with phone and Email
DESIGN CUSTOMER INFORMATION
Internal distributor assigned account number for the customer
Country location of the customer
Mfg. Rep. or Sales Person
Applicable manufacturer’s representative assigned to the account with phone and Email. This can be the Rep firm if no individual is identified.
Applicable manufacturer’s responsible sales person with phone and Email
Check: “Concept”, “Prototype”, “Design Win”, or “Production Win” depending on project progress to date
Date the prototype was constructed or is expected to be constructed. MMDDYYYY
Estimated date the project will go into production. MMDDYYYY
Name of the project involving the part subject to registration
Estimated Annual Unites - Number of devices, systems, or units to be built under this project
Description (Application)
Description of the application or elements of the project
Name assigned to the board where this part will be placed
Project Engineer, Phone, Email
Customer’s engineer assigned to manage the project with phone and Email
Additional Engineer, Phone, Email
Any other engineers critical to the project with phone and email
Purchasing Contact, Phone, Email
Name of the person who will be directing the purchase of the registered part with phone and email
PART NUMBER FOR REGISTRATION
Enter the complete part number including packaging information where available. This can be the part number or the part description/family.
There should be only 1 part number per Socket.
R/A R=Registerable A=Associated
Indicate “R” if this is a part for Registration or “A” if this is an Associated part
Description of the device (i.e.: Microcontroller)
Standard Distributor Cost
Distributor Target Resale Price
Total number of devices to be used on this project
Total Part Qty. X Target Resale
Indicate supplier registration level where applicable or enter comments on part here
3 Levels: Distributor only, joint, fulfillment
Part number assigned by the customer
Competition Manufacturer’s name
Unit price customer is paying for the competitor’s part.
Enter any comments that might have an effect on this design
The date the registration was accepted or rejected. MMDDYYYY
Enter registration number when approved
The reason for the rejection
Date the registration expires or must be renewed. MMDDYYYY
Distributors Account Number
Manufacturer account number assigned to the Distributor
Unique ID for this branch if applicable
Any general comments regarding the registration.