Request Form for IEEE Assignment of an IEEE MAC Address Medium

Request Form

You will receive your assignment within seven (7) business days of the receipt of this application and payment. If IEEE Registration Authority places the application on hold for any reason, the applicant has thirty (30) days to rectify the problem. If the problem is not rectified within thirty (30) days, the application process will be terminated and the applicant can re-apply once they have resolved the issue.

IEEE does not honor requests for applicant-specified identifiers. Assignments are public unless specifically requested otherwise.


Registration Information

(All fields in bold are required. Click ? for more information about each field.)

Part 1

Requestor Information
 
 Requestor Name ?  
 Job Title ?  
 Company Name ?  
 Address Line 1 ?  
 Address Line 2 ?  
 City ?  
 State/Province ?  
 ZIP or postal code ?  
 Country ?  
 Phone Number ?  
 Fax Number ?  
 E-mail Address ?  

Part 2

Administrator Information
 
    Administrator's Name ?  
    Job Title ?  
    Company Name ?  
    Address Line 1 ?  
    Address Line 2 ?  
    City ?  
    State/Province ?  
    ZIP or postal code ?  
    Country ?  
    Phone Number ?  
    Fax Number ?  
    E-mail Address ?  
 

Part 3

Company Information

Please Note: If "No" is chosen the Registration Authority requires that you use 95% of the existing assignment number before an additional number can be issued to you. Parent and subsidiary companies can share assignments.

If this requirement cannot be met, the IEEE can issue an additional assignment to your Company providing you send a letter on Company letterhead stating that you will not ship product on the new assigned number until 95% of the existing number is used. Your Company should ensure that large numbers of the derived identifiers are not left unused. If the existing assignment is 95% used, please fax the usage percentage letter to +1 732-562-1571. Please be sure to reference the tracking number that will be sent in an e-mail once application is submitted.
Initial corporate assignment request?  
(If your answer above is No, under what
Company name have you requested
an assignment?)
If you are requesting an additional assignment, please provide reason:
Your Company type ?
If Parent or Subsidiary is checked, please complete Part 4.

Part 4

Related Company Information ?

If the Company listed above is a Parent because it has its own subsidiaries or the
Company above is the subsidiary of another organization, then you must identify
the names of any Parent or Subsidiary by filling in information below for up to three
related organizations.If you have more than three entries, please make copies
of this form to supply the required information. Fax the completed form to +1 732-562-1571.

Related Company 1
 Contact's Name  
 Contact's Title  
 Organization/Company Name  
 Address Line 1  
 Address Line 2  
 City  
 State/Province  
 ZIP or postal code  
 Country  
 Phone Number  
 Fax Number  
 E-mail Address  
Company type


Related Company 2
 Contact's Name  
 Contact's Title  
 Organization/Company Name  
 Address Line 1  
 Address Line 2  
 City  
 State/Province  
 ZIP or postal code  
 Country  
 Phone Number  
 Fax Number  
 E-mail Address  
Company type


Related Company 3
 Contact's Name  
 Contact's Title  
 Organization/Company Name  
 Address Line 1  
 Address Line 2  
 City  
 State/Province  
 ZIP or postal code  
 Country  
 Phone Number  
 Fax Number  
 E-mail Address  
Company type

Part 5

Confidentiality Information ?

Do you want the Company name and address to remain confidential so that it is not on the public listing?  
Should Company avail itself of the option to keep its Company and identifier confidential, the IEEE shall take all reasonable steps to maintain confidentiality. However, Company hereby agrees that, should confidentiality be breached other than due to IEEE’s negligence or intentional act, the IEEE shall not be liable for any compensatory or special damages, including, but not limited to, consequential, exemplary, special, incidental, punitive, liquidated, direct or indirect damages or attorneys fees in connection with such breach. Furthermore, even if the breach resulted from the negligence of the IEEE, the cumulative liability for any and all claims, regardless of the form of action, arising out of, or relating in any way to, this Agreement shall not exceed the total amount received by the IEEE from Company, during the term in which any breach may occur. Signor represents that he or she has the authority to bind theCompany to the limitation described above.  
 
If No is checked, skip Part 5.
If the Company and its identifier are to be held confidential, the reason for confidentiality must be detailed below.
Assignees are required to notify the IEEE Registration Authority (IEEE RA) of any changes to the following information: Company Name, Administrator, Company Address, Telephone Number, Fax Number, E-mail Address.

The annual fee for confidentiality is due on the date the assignment was originally issued (anniversary date). Assignees will receive an email from the IEEE RA 60 days prior to the anniversary date of the assignment for remittance of the annual confidentiality fee.

Assignees will have sixty (60) days from the date of the invoice to forward the annual confidentiality fee to the IEEE RA. If the IEEE RA is unable to contact the assignee during the 60 day period and/or if the IEEE RA does not receive the annual confidentiality fee after the 60 day period, the Company name and address will be listed on the public registry.


Part 6

Payment Information

Payment method: ?  






Company hereby agrees to indemnify and hold IEEE, its officers, directors, employees and agents harmless from any claim arising out of Company's use or misuse of any assigned number. Signor agrees to notify IEEE of any changes of address or contact information. IEEE Registration Authority is unable to process any application without Company agreeing to indemnify the IEEE described above by accepting the statement. Signor represents that he or she has the authority to bind the Company to the indemnification obligation.




If there are any questions regarding this form, please e-mail ieee-registration-authority@ieee.org or call +1 732-465-6481.

To subscribe to the IEEE RAC Public Reflector, please see Subscribing to the Standards RAC Public Reflector --> Make a note of the Mailing List Name: stds-rac-public