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Relationship with Belden or one of its subsidiaries or affiliates (please check all that apply): CustomerFormer CustomerProspective CustomerEmployeeFormer EmployeePotential EmployeeSupplierOther (please specify)

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Belden affiliate or brand with which you have a relationship. For the purposes of this question, each affiliate includes its foreign subsidiaries. Please check all that apply: BeldenGarrettComHirschmannLumberg AutomationTofino SecurityMohawkPPCAlpha WireWest Penn Wire

Nature of your request (please check all that apply): Who are you? Why and how are you processing my data? (Basic Information)Please confirm that you process my personal data, please provide a summary of your processing activities and a copy of my personal data in your possession (Access)Please provide my data to me or a new data controller in machine readable form. (Portability) Please correct certain errors in my personal data (provide additional detail below). (Rectification) Please erase personal data that you have related to me. Please provide detail in the space provided below. (Erasure) Please stop using my personal data for the purposes described below. (Restriction on Use) I disagree that you have a legitimate interest in processing my data. Please stop any such processing. (Objection to Use) Please do not send me any additional direct marketing materials (Objection to Direct Marketing) Please stop using my personal data to make automated decisions that affect me. (Objection to Automated Processing) Other (please provide additional detail in the space provided below)

Please also provide a narrative summary of your concern or request order to allow us to most efficiently process your request:

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Yes, I would like to receive marketing information from Belden Inc. and its subsidiary companies and brands. By selecting this box and submitting this form, I agree that Belden is permitted to use the personal information provided herein to contact me regarding the requested sample. I provide my consent to Belden Inc. and its subsidiaries and brands to store, process and use the personal information submitted for the purpose of providing marketing information related to their products, services and marketing events. I understand that I may withdraw my consent at any time. Additional information regarding Belden's data privacy policies, including how to withdraw consent, is available at Belden.com/about/privacy. Belden Inc. and its subsidiary companies and brands include: Belden Deutschland GmbH; Hirschmann Automation and Control GmbH; Belden Wire & Cable B.V.; GarrettCom; Lumberg Automation, and Tofino Security.