Modular Cord Line

Custom Cable Assembly Quote Request

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

Modular Cord 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
Cable: Generic Brand - Enter Brand: Category:
Number of Pairs: Wire Type:
Color: Length: Jacket Type:
Total Qty Blunt or Double Ended?
Double Blunt
Packing Request: Single 5 At A Time Bagged? Yes No
Label: No Label Left Right Both Label Location:
Label Content:
Sticker Data:Footage Custom


LEFT CONNECTOR
Booted? Yes No
Connector Type If 110 Enter Number of Pairs If Other Enter Type
Wiring/Color Code If Other Explain Wiring/Color Code to Use
Multiple Legs Yes No Number of Legs Staggered? Yes No Length of Legs See Special Instructions

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 If 110 Enter Number of Pairs If Other Enter Type
Wiring/Color Code If Other Explain Wiring/Color Code to Use
Multiple Legs Yes No Number of Legs Staggered? Yes No Length of Legs See Special Instructions

SPECIAL INSTRUCTIONS:

SHIP TO INFORMATION

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

BILL TO INFORMATION

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

*Send Quote To Me By: EMail FAX Call Me