Contractor Advantage Enrollment Form

Please provide the information below so we can best serve you

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* 1. Contact Information

First Name

Last Name

Title

Company

Street Address

City

State

Zip Code

Business Phone

Mobile

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* 2. Please provide you shirt size:

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* 3. Do you play Golf?

Yes

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* 4. Please tell us your Hobbies:

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* 5. How were you referred to the Contractor Advantage Program?

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* 6. Which of the following Contractor Advantage benefit areas do you wish to participate/enroll in? (Check all that apply - see Contractor Advantage Brochure for details)

Contractor Rewards Program

Product Evaluation Program

Live Training – Contractor Workshop

Live Training – NFPA 70E

CEU Accreditation

Digital Marketing Services

Programs, Promotions, Events

Access to Leviton’s Market Knowledge Information System

Energy Management Design Assistance Services

Contractor Business Summit

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* 7. If you selected “CEU Accreditation” in the previous question, please provide your state and Electrical License Number for CEU reporting purposes

License #, License Expiration, Date of Birth

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* 8. Do you work with builders on new home construction?

Yes

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* 9. Are you currently buying Leviton products?

Yes

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* 10. If you ARE purchasing Leviton products, what types of products are you buying? (Check all that apply)

Basic Wiring Devices

Low-Voltage, Datacom, and Connected Home

Dimmers

Energy Management

Home Automation

Other (please specify)

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* 11. If you ARE currently buying Leviton products, please provide the name of your Leviton Sale Rep below:

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* 12. What is the percentage (%) breakdown you buy from each Wiring Device Manufacturer: (Answers must total 100%)

P&S %

Hubbell %

Leviton %

Cooper %

Lutron %

Other %

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* 13. What types of work do you do? (Check all that apply)

Residential

Commercial

Industrial

Low Voltage

MRO

Service

Other (please specify)

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* 1. Contact Information

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* 2. Please provide you shirt size:

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* 3. Do you play Golf?

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* 4. Please tell us your Hobbies:

Question Title

* 5. How were you referred to the Contractor Advantage Program?

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* 6. Which of the following Contractor Advantage benefit areas do you wish to participate/enroll in? (Check all that apply - see Contractor Advantage Brochure for details)

Question Title

* 7. If you selected “CEU Accreditation” in the previous question, please provide your state and Electrical License Number for CEU reporting purposes

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* 8. Do you work with builders on new home construction?

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* 9. Are you currently buying Leviton products?

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* 10. If you ARE purchasing Leviton products, what types of products are you buying? (Check all that apply)

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* 11. If you ARE currently buying Leviton products, please provide the name of your Leviton Sale Rep below:

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* 12. What is the percentage (%) breakdown you buy from each Wiring Device Manufacturer: (Answers must total 100%)

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* 13. What types of work do you do? (Check all that apply)

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* 14. Estimated Annual Total Wiring Device Purchases: