Please fill out the following form and either e-mail it to us by pressing the SUBMIT button at the bottom, or by printing it and faxing it to us at 631-842-1005.

Contact Information

Name

Company

Email

Address:

City:

State:  Zip:

Phone

Fax: 

Part Number: 

Quantities to Quote (EAU) 

Design Stage:  Select the Stage New Design Re Design Existing Design

Do you have a drawing?   Select Yes No

Do you have a sample?  Select Yes No

Specifications:

Size (Length and Width):

Circuit Tail length: 

Tail Exit Point:
  Select Top Bottom Left Right

Tail Termination: Select Connector Exposed Conductors (ZIF)

Key Type: Select Non-Tactile Tactile Metal dome Tactile Poly Dome Tactile Domed Overlay

Embossing:  Select None Full Key Perimeter Key Right

Number of Tail Positions: 

Overlay Finish: Select Textured Glossy Antiglare

Display Window:  Select None Textured Glossy Antiglare

Number of LEDs: 

Number of Keys:

Number of Colors: 

Number of Filters: 

Support Panel:  Select None Aluminum Polycarbonate Other

Thickness: 

Finish: 

Hardware: 

Shielding:  Select None Printed Graphite Printed Silver Foil Other

Sealing Requirements: Select NEMA 4 Standard

Additional Requirements: