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Sample Order Form
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Please fill out order form: Created on Date: 10/21/2017 Time 06:05:59 AM
Sample Number:2017-136649
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Enter Validation
Code: 77AC8

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Name:
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Company:
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Address:
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City:
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State/province:
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Zip/postal code:
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Country:
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Shipping Method
If other than FCM enter Acct. # below
Account Number
Phone Number:
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Fax Number:
E-mail Address:
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Ref # or Project Name:
Purpose Code: *
End Customer Market *



KSE Representatives, KSE Distributors & Contract Manufacturers (Only)
End Customer:
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End Customer Contact:
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Contact's Phone #:
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Ref # or Project Name:
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* Required Field
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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 determine the possibility of meeting your request.
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Item No.
KOA Part Number
Customer Part Number
Quantity
Max of 100 pieces
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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
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Thank you.

KOA Speer Electronics, Inc.
Copyright 2000, All rights reserved.
Updated 09/18/2003
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