Sample Order Form

Please fill out order form: Created on Date: 03/11/2010 Time 05:49:01 AM
Sample Number:	2010-69707

Name:	*
Company:	*
Address:	*

City:	*
State/province:	*
Zip/postal code:	*
Country:	*
Phone Number:	*
Fax Number:
E-mail Address:	*
Ref # or Project Name:
End Customer Market:	*	Alternative Energy Consumer Commercial Military/Aerospace Transportation Consumer Home Networking Cellular Industrial Power Supply Computer Medical Telecom
KSE Representatives, KSE Distributors & Contract Manufacturers (Only)
End Customer:	*
End Customer Contact:	*
Contact's Phone #:	*
Ref # or Project Name:	*
* Required Field

Enter full part number from the ordering and specifying information from the data sheets.
Incorrect and/or Non-Valid Part Numbers will automatically be deleted from the sample order.

All samples will be shipped in "Bulk" form and will be processed as "Lead-Free" and will ship via First Class mail. If you require product on tape and reel, quantities greater than 100 pieces, or better shipping, please contact KOA Speer's Customer service @ (814) 362-5536 ext 224, to detemine the possibility of meeting your request.

Item No.	Part Number	Quantity Maximum of 100 pieces
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

All samples will ship from the KOA Sales Office that handles your area.

If you have any questions
please call your local sales representative.
or E-mail to:............. KOA Speer Marketing

.
.