First Name: Required Enter First Name	Last Name: Required Enter Last Name	Title Enter your position title
Company: Required Enter Company Name:	Phone: Required Enter Phone Name:	Fax: Required Enter Fax Number:
Email Address Required
Address Line 1: Required Enter Address Line 1:
Address Line 2: Enter Address Line 2:
City: Required Enter City name:	State: Required Enter State:	Zip Code: Required Enter Zip (Postal) Code:
Country: Enter 3 digit country code: (i.e. USA)
Corporate Website

Quotation Parameters

Design State Select the State of your design New Design Re Design Existing Design
Quantities to be quoted

Part Number: Your internal part number:	Revision_Number: (ie. v0.21)
Desired Delivery Date: MM/DD/YYY	Annual Quantity: Enter annual quantity used:
Expected Life: Enter expected life:	Target Price: Enter target price:

KeyPad Specifications

Keypad Size:

Indicate standard (in or mm)

Base Specifications of Pc Board

PC Board Material

PC Board Thickness

PC Board Size

Sides

Single Sided Double Sided

Plated Through Holes

Foil Thickness

Foil Finish

Solder Mask Required

One Side Both Sides

Nomenclature Required

One Side Both Sides

PC Board Interface (Connection) Method

Customer Supplied Artwork Available

Circuitry Letter Screen Solder Mask

Additional Components

Attach a File

Files must be less than 4MB

Additional Comments

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