Request For Quote

All fields below are required in order to produce an accurate quote which will be provided within 2 business days.

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:

Phone:

Part Number:

Design Stage:

Do you have a drawing?

State:

Zip:

Fax:

Quantities to Quote (EAU):

Do you have a sample?

Specifications:

Size (Length and Width):

Tail Exit Point:

Key Type:

Number of Tail Positions:

Display Window:

Number of Keys:

Number of Filters:

Thickness:

Hardware:

Sealing Requirements:

Circuit Tail length:

Tail Termination:

Embossing:

Overlay Finish

Number of LEDs:

Number of Colors:

Support Panel:

Finish:

Shielding:

Additional Requirements:

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