Submitted By: Click or tap here to enter text.

Date: Click or tap to enter a date.

Company Information

Company Name: Click or tap here to enter text.

Address: Enter text

City: Enter text State: Enter text Zip: Zip

Country: Click or tap here to enter text.

Contact Name: Click or tap here to enter text.

E-mail Address: Click or tap here to enter text.

Phone Number: Click or tap here to enter text.

Country of Installation: Click or tap here to enter text.

Address of Installation (if different): Click or tap here to enter text.

Project Information

Project Budget: Click or tap here to enter text.

Expected Purchase Date: Click to enter a date.

Expected Delivery Date: Click to enter a date.

Part Description

Part Description: Click or tap here to enter text.

Manufacturing Process Used: Click or tap here to enter text.

Largest Part Dimensions: (Length) Click or tap here to enter text.

(Width / Dia.) Click or tap here to enter text.

(Height) Click or tap here to enter text.

Maximum Part Weight: Click or tap here to enter text.

Type of Indication Expected to Be Discovered: Click or tap here to enter text.

Expected Run Rate (Parts per Hour): Click or tap here to enter text.

Facility Information

Current Utilities Available:

(Voltage) Click or tap here to enter text. / (Amperage) Click or tap here to enter text.
(Phases) Click or tap here to enter text. / (Air in psi) Click or tap here to enter text.

Equipment Description

Available square footage for system: Click or tap here to enter text.

Preferred Input Voltage: Click or tap here to enter text.

Maximum Current Output Expected (amps): Click or tap here to enter text.

Current type: Click or tap here to enter text.

Technique Storage: ☐Yes☐No

Auto-bath: ☐Yes☐No

Conveyor with Inspection Booth:☐Yes☐No

Bath Type: ☐Oil Bath☐Water Bath

UV Lamps for Inspection:☐ST700☐EV6500 ☐EV6000

For Office Use Only

Customer Number: Click or tap here to enter text.

Quote Number: Click or tap here to enter text.

Purchase Order Number: Click or tap here to enter text.

Estimated ship date ARO: Click or tap here to enter text.

Pain Points to Address: Click or tap here to enter text.

Industry Segment: Choose an item.

Behavioral Segment: Choose an item.

Enter opportunity into Salesforce: Instructions here

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