EPIX® Information Request Form Please fill out as much information as you can so that we may better assist you. If any fields do not apply to you, leave them blank. Contact Information: Name: Title: Company / Organization: Mailing Address: City: State / Province: Country: Zip / Postal Code: Phone: Fax: E-mail: I would like to be placed on the mailing list: Yes No Already on list EPIX, Inc. does not sell your information to any 3rd parties. If you elect to join the mailing list, you will only receive news and information from EPIX, Inc. I would like an EPIX® sales representative to contact me by: Email Phone Fax I am interested in: (check all that apply) Board: PIXCI® ECB1-34 PIXCI® EC1 PIXCI® ECB2 PIXCI® EB1 PIXCI® EB1-PoCL PIXCI® EL1 PIXCI® EL1DB PIXCI® E4 PIXCI® E4DB PIXCI® e104x4 PIXCI® E8 PIXCI® CL1 PIXCI® CL2 PIXCI® D2X PIXCI® D3X PIXCI® A310 PIXCI® SV8 PIXCI® SV7 PIXCI® SV5 PIXCI® SV5A PIXCI® SV5B PIXCI® SV5L PIXCI® SV5S Camera Kit: SILICON VIDEO® 643C SILICON VIDEO® 643M SILICON VIDEO® WGAC SILICON VIDEO® WGAM SILICON VIDEO® 1C45 SILICON VIDEO® 1M45 SILICON VIDEO® 9M001 SILICON VIDEO® 9T001C SILICON VIDEO® 5C10 SILICON VIDEO® 5M10 SILICON VIDEO® 9C10 SILICON VIDEO® 10C6 SILICON VIDEO® 10M6 SILICON VIDEO® 15C5 SILICON VIDEO® 642M SILICON VIDEO® 1281C SILICON VIDEO® 1310C SILICON VIDEO® 2112C Software: XCAP XCLIB PXIPL TWAIN Drivers ImagePro Drivers Comments: Describe your imaging application(s). What camera(s) do you use? How did you locate our site? What computing platforms do you use? Any questions on our products? Other comments or suggestions?