First Name:
Last Name:
Email:
Phone:
Address:
City, State, Zip
How Did you Find Us:
Select
Google (Organic)
Google (AdWords)
Bing (Organic)
Bing (AD)
Yahoo (Organic)
Yahoo (AD)
Facebook
Referal
Describe Your Project Request:
Data Distrbution
What type of internet will you use?
Select
Cable
DSL
Satellite
FIOS
UVerse
How many locations would you like for
active internet?
Select
1
2
3
4
5
6
7
8
9
10+
Will you be using CAT 5e cable or CAT 6
cable?
Select
Cat5e
Cat6
Will you be creating a wireless network
as well?
Select
Yes
No
Will you be mounting 3rd party
equipment in the Leviton SMC? (modem, router, etc)
Select
Yes
No
Telephone Distrbution
How many locations would you like
telephone service? (Note: standard phone service will allow up to 12 locations
to ring at a time)
Select
1
2
3
4
5
6
7
8
9
10+
Will your security system be tied to
your telephone line?
Select
Yes
No
Cable TV Distribution
Will you have cable TV or satellite
service?
Select
FIOS/UVerse
Cable
Satellite
Antenna
How many coaxial cable TV locations do
you want?
Select
1
2
3
4
5
6
7
8
9
10+
How many coaxial cable TV locations do
you want connected simulaneously? (For example, you might run 20 coaxial cable,
but will only use 8 at a time?)
Select
1-8
9-16
Power
All Leviton Structured Media Centers will be configured with
surge protected power supplies to provide protection for the active equipment
inside the enclosure. Customer will need to have licensed electrician
connect house wiring to panel.
Audio
Basic Distribution: Single
Source, up to 6 zones, slide volume control
How many basic zones (left and right
speaker, one volume control, indoor - does not include home theater/surround
sound area)?
Select
1
2
3
4
5
6
How many small or bathroom zones
(locations where there may be room for only a single speaker)?
Select
1
2
3
4
5
6
How many outdoor zones?
Select
1
2
3
4
5
6
Type of Outdoor Speakers?
Select
Surface Mount
In Cieling
Any other details you can provide to allow us to
better understand your application (i.e. existing products/systems, existing
wiring, special considerations regarding building structure, etc.)?
Residence Information
House Status?
Select
Completed
Under Construction
How many floors?
Select
1
2
3+
Are cable runs between floors?
Select
Yes
No
Attic Space?
Select
Large Open Attic
Standard Attic Space
Minimal Attic Space
No Attic Space
Crawl Space?
Select
Yes
No
Exterior Runs Permitted
Select
Yes - Exposed Cable
Yes - Cable in Surface Raceway (Office White - Paintable)
Yes - PVC Conduit
Yes - Metal Conduit (Rigid or Flex)
No
Trenching Required
Select
Yes
No
Additional Network Hardware
Do you require a Router?
Select
Yes
No
Unsure
Do You require Wireless?
Select
Yes
No
Do you require a Switch?
Select
Yes
No
Unsure
Additional Hardware?
Will you need these products installed and configured?
Select
Yes
No
