Company *

Date

Street *

Job Ref No:

Suite / Dept / M_Stop

Job Title:

City *

Tel No *

State + Zip *

Fax No *

Country *

Email *

Your Full Name *

Website *

Annual Usage *

Target Price

Estm. Buy Date *

Current Source

Current Mfg

Current Part No

New Application

Yes    No

Application Life *

Engineer’s Name *

Buyer’s Name *

Buyer’s Tel No *

Engineer’s Tel No*

Is a drawing / data-sheet / sample / prototype available ? Which   

How did you find our company / website : Select Customer Referred Search Engine Website New Other                                     Are you an existing Customer?    Yes   No

 Connector Specs for the Cable Assembly

Description

Left Hand Side

Right Hand Side

Hook Up Diagram

Connector P/N

Std. Hookup is 1 to 1. Enter RHS pin # to Connect to LHS

Connector Manufacturer

LHS

1

2

3

4

5

6

7

Connector Type

RHS

Number of Contacts

LHS

8

9

10

11

12

13

14

Sex of Contacts

RHS

Type of Backshell

LHS

15

16

17

18

19

20

21

Type of Hardware

Cable / Wire Specs for the Cable Assembly

Cable Style:   Round, Multi-conductor Flat Ribbon Cable Telephone Type Stranded Wire Coaxial Wire Hook Up Wire       No of Conductors      UL Style:   AWG Wire Size 

Cable Manufacturer: Mfg P/N: Jacket Color:     Jacket Material 

Cable Length ( Inch)       Outside Diameter (inch)       Temp Range  + F to - F

Shield Type:     Braid       Mylar Foil + Drain Wire       None       Coax   Type :

Conductor Type: Solid    Stranded   Tinned     Stripped    Half Stripped     Strip Length (inch) 

 Remarks: