REQUEST FOR QUOTE: PARTS & SERVICES

* Fields highlighted in red are required

CONTACT INFORMATION

* First Name: * Last Name: * Company Name: Street Address: City: State: Select One... Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusets Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Verginia Wisconsin Wyoming Zip Code: Telephone: -- Fax: -- * E-mail:

SERVICE RELATED ISSUES

Machine Type: Manufacturer: Wayne Trail Technologies VIL Livernois Other Machine Serial Number: Please describe the problem: Has this problem occurred before? Yes No If so, when? Do you want to schedule a service call? Yes No Do you require a copy of our current service rate sheet? No Yes

SPECIFIC PART INFORMATION

Complete this section for each part to be quoted or ordered.

Part #1 Part #2 Part #3 Type of machine: (flexbender, transfer,etc.) Machine Serial Number: If commercial part, please identify part manufacturer: (Parker, PHD, Turck, etc.) Part Number: If no part number, identify location on machine and provide description: Number of pieces wanted? If these are to be placed on order now, advise purchase order number (and fax hard copy to 937-295-2642) Shipping address: Billing address: Same Same Same Ship Attention To:

SHIPPING INFORMATION

Special Shipping Instructions: (Or Preferred Carrier)