e-Twin@x Controller
Request Form

I would like to…

Purchase
Evaluate
Have a specialist contact me
Have more information sent

Name

Company Name

Address

City

State

Zip

Phone

Fax

e-mail

Industry:

Manufacturing

Healthcare

Distribution

Government

Retail

Other:

Number of remote locations:

1-5     6-10     11-25     26+

Existing Twinax controllers: (check all that apply)

IBM 5394 Perle 494
IBM 5494 Perle 594

Other:

e-Twinax Model Required:

4693 (3 device) 4628 (28 device)
4610 (10 device) 4656 (56 device)
4616 (16 device) 4612 (112 device)

Connection from AS400 and users:

Local Twinax WAN Frame relay

Local Ethernet

Internet w/Router

WAN leased lines

Internet dial up/out

Devices you intend to connect to controller: (check all that apply)

Twinax display stations

SCS Twinax printers

PCs with Twinax 5250 emulation

IPDS Twinax printers

Other:  

I heard about these products from…

Direct mail piece

Trade show/seminar

Display ad in magazine

Yahoo/Web search

Referral

Other

Additonal Comments: