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First Name:* Last Name:*

Title: Company Name:*

Address:* City:*

State/Province:* Zip/Postal Code:*

Country:* Phone:

Fax: E-Mail Address:

Where Did You Get Our Web Address? (Select One)

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	Electronic Distributor:
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	Product Interest (Check all that apply)
	Amphenol RF/Connex Antenna Rotators Cable Ties Capacitors Chemicals - Aerosol Clips/Test Leads CML Innovative Tech (Chicago Miniature Lamp) Coast LED Flashlight Digital Infrared Thermometer ECG Flashlights Flameproof Resistors Fuses Heat Shrink Tubing Hook-Up Wire ITW/Dymon - Waterless Towels Kester Solder Products LED Tubing	Plato Solder Tips Potentiometers/Trimmers ProVision Fiber Optic Scopes Proximity Switches Psiber Multifunction Cable Tester Quick Cross Software Relays SCRUBs - Waterless Towels Semiconductors Soldering and Heat Products Stancor Surge Outlet Strips Switches Techspray Chemicals Terminals and Connectors Test Equipment UNICOM Voice/Data Products Wireless Inspection Camera

	Industry (Check One)
	Hospital Consumer Service and Repair University/College/Technical School Utility Public Works/Government OEM - prototyping/R & D OEM - production/manufacturing OEM - maintenance/repair and operations Plant maintenance/repair (MRO) Contract assembly manufacturer Broadcast Industry

Purchase Information

	Do you currently buy NTE products?	Yes No
	If yes, from whom?
	In what city are they located?
	In what state/province are they located?
	In what country are they located?
	Is your need:
	What is the application for our products?
	What type(s) of products do you have a hard time finding through your local distributors?

Please use e-mail for any comments or questions that you may have.

	* = required
	First Name:*		Last Name:*

	Title:		Company Name:*

	Address:*		City:*

	State/Province:*		Zip/Postal Code:*

	Country:*		Phone:

	Fax:		E-Mail Address: