Company:

First:

Last Name:

Title or Position:

Address:

City:	State:		Zip:
Country:
Phone:	Ext:	Fax:
Email:

Type of Company:
	OEM		Import/Exporter		Contract Mfg
	Distributor		Engineering Firm		Other

New Design:	Existing:		EAU:
Application:		Timeframe:
Samples for: Prototype      First-Production      Other:

Mfg: Part Number:	Qty Needed:	Mfg: Part Number:	Qty Needed:
Competitors Part Number:
Comments: