Data

Custom Cable Assembly Quote Request

Please complete the form below and click on the submit button at the bottom of the form. Our Customer Service Reps will return the quote to you by the method you request below. If you have any questions or need help filling this form out please call us at 1-800-327-4642 Option 4.

Company Information

*Company Name New Customer? Yes No
Address
City State Zip Code
*Contact Name *EMail Address
*Telephone Extension Fax

* Required Field

Data Specification

Left Connector Right Connector 
           Label

Need Help? Call Our Customer Service Representatives 8:00 AM - 5:30 PM Eastern Standard Time Monday - Friday, at (800) 327-4642 Option 4

GENERAL INFORMATION
Date Required: Quote Number (Internal Use Only):
Cable: Generic Brand - Enter Brand:
Shielded? Yes No Jacket Type: PVC Plenum
Length: Total Qty
Bagged? Yes No
Label: Left Right Both Label Location:
Left Label Content:
Right Label Content:


LEFT CONNECTOR
Booted? Yes No
Connector Type Enter Number of Contacts
If Other Enter Type 		See Wiring Instructions See Special Instructions
Multiple Legs Yes No Number of Legs Length of Legs Staggered?
Yes No		 Length of Staggered Legs

Need Help? Call Our Customer Service Representatives 8:00 AM - 5:30 PM Eastern Standard Time Monday - Friday, at (800) 327-4642 Option 4


RIGHT CONNECTOR
Booted? Yes No
Connector Type Enter Number of Contacts
If Other Enter Type 		See Wiring Instructions See Special Instructions
Multiple Legs Yes No Number of Legs Length of Legs Staggered?
Yes No		 Length of Staggered Legs

WIRING INSTRUCTIONS:

SPECIAL INSTRUCTIONS:

SHIP TO INFORMATION (Optional)

Same as Above
Company Name
Address
City State Zip Code
Contact Name

BILL TO INFORMATION (Optional)

Same as Above
Company Name
Address
City State Zip Code
Contact Name
Telephone Extension Fax

*Send Quote To Me By: EMail FAX Call Me

* Selection Required