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Your Name
Job Title
Company
Div/Dept.
Address 1
Address 2
City/State
Country
Business Phone
Business Fax
E-mail address
Your Birth Month		Please select the month you were born as your personal identifier. This will be used by our auditor only to confirm the validity of your application and will not be used for any other purposes.
		Please select January February March April May June July August September October November December

1. What type of business do you work for ?
01.	Manufacturer
	If you are a manufacturer: Do you provide electronic manufacturing service or subsconract manufacturing? Yes No
02.	Distributor, importer/exporter
03.	R&D lab, academic institute
04.	Others allied to the field (Please specify)

2. What is the main end product or service at your location?
05.	Electronic components
06.	Semiconductor devices
07.	Electronic subassemblies (boards, modules, hybrid ICs, display modules)
08.	Test & measuring instruments
09.	Production, factory automation equipment
10.	Electronic materials & chemicals
11.	Computers and peripherals
12.	Communications equipment
13a.	Consumer electronics products
14a.	Car electronics products
15.	Office and business machines
16.	Others (Please specify)

3. Which best describes your job function?
17.	General & corporate management
18.	Product design and development
19.	Research and development
20.	Manufacturing and production
21.	Quality control, testing
22.	Maintenance, engineering assistance
23.	Purchasing & procurement
24.	Marketing and sales
25.	Others (Please specify)

4. Your job title:
26.	President/management exective
27.	General manager/director
28.	Manager
29.	Section head
301.	Engineer
31.	Consultant
302.	Other title not classified elswhere (Please specify)

5. Number of employees at your location:
331.	1-99	37.	500-999
35.	100-249	38.	More than 1,000
36.	250-499

6. In my job, I recommend, specify or authorize purchasing of:
39a.	General Electronic Components	47a.	Batteries & Power Supplies
40a.	Car Electronics Components	48a.	Data Storage & Recording Media
41a.	Semiconductors (include PCBs)	49a.	Computers & Peripherals
42a.	Display Device Modules (LCD, PDP, LED etc)	50a.	CAE/CAD/CAM Systems
43a.	Test & Measuring Instruments	51a.	Embedded Development Tools
44a.	Semiconductor Production Equipment	52a.	Software
45a.	Other Production Equipment (SMT, Robotics etc.)	53a.	Others (Please specify)
46a.	Materials & Cables	54a.	None of the above

7. What electronics industry publications do you receive addressed to you personally?
631.	Electronic Engineering Times	66.	Nikkei Electronics Asia
64.	EDN Asia	67.	Electronics Product New Asia
65.	Electronics Business Asia	68.	Others

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