REQUEST FORM

In order to expedite your request for a quotation, please print and fill out this form and fax it back to us at (203) 853-9304 Attn. Sales. We will review your request and make every attempt to return your inquiry within 24 hours.


COMPANY: ________________________________________________

ADDRESS: ________________________________________________

CITY/STATE/ZIP: ___________________________________________

PHONE: _________________________________

FAX: ____________________________________

CONTACT: ________________________________________________

DEPARTMENT: ________________________________________________


PRODUCT TO QUOTE ON: (Please check off all specifications)

___ DOMESTIC ___ INTERNATIONAL

___ CORD SET ___ DETACHABLE CORD SET

___ HOSPITAL GRADE CORD SET ___ BULK WIRE

___INTERNATIONAL CORD SET MALE PLUG ___ FEMALE PLUG ___ BOTH

SPECIFICATIONS:

2&3 CONDUCTOR "SPT" TYPE

___ 24/2 ___ 22/2 ___ 20/2 ___ 18/2 SPT-1 ___ 18/2 SPT-2 ___ 18/3 SPT-1

___ 18/3 SPT-2 ___ 16/2 SPT-2

2&3 CONDUCTOR "ROUND STYLE"

___ 18/2 SJT ___ 18/2 SVT ___ 18/3 SJT ___ 18/3 SVT ___ 16/2 SJT

___ 16/3 SJT ___ 14/2 SJT ___ 14/2 SJT

LENGTH:_________ MALE PLUG:_________ HOSP. PLUG _________

FEMALE PLUG: _________

COLOR:

___ BLACK ___ WHITE ___ BROWN

___ CLEAR GOLD ___ GREY ___ OTHER


SILT_________ " STRIP_________ "

REMOVE OUTER JACKET (ROUND STYLE ONLY)_________ "

ENDS TINNED_________ ENDS TERMINATED _________

(VENDER & PART #) _____________________________________

FOLD & TIED (HANKED): _________

BUNDLES (UNHANKED): _________

QUANTITY: _________

EST. ANNUAL USAGE: _________

BULK WIRE: (Check off specs from above)

AMOUNT PER REEL_________ FT

TOTAL FOOTAGE_________ FT


INTERNATIONAL CORD SETS

COUNTRY_________

LENGTH _________

2 CONDUCTOR _________ 3 CONDUCTOR _________ BOTH _________

MALE _________ FEMALE _________ BOTH _________

REMOVE OUTER JACKET _________ " STRIP INNERS _________ "

ENDS TINED _________ ENDS TERMINATED _________

(VENDOR NAME AND PART #)

COLOR:

____ BLACK ____ WHITE ____ LIGHT GREY ____ DARK GREY

FOLD & TIED (Hanked) _____________________

QUANTITY ______________________

ESTIMATED ANNUAL USAGE ___________________


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LION CORDS
A division of Astrophonic Corporation of America
149 Woodward Ave, S. Norwalk, CT 06854

Tel (203) 853-9300 Fax (203) 853-9304
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