Company Name

Address

City

State

Zip

Phone

Fax

e-Mail

Web Site

Part Number

Revision

Description

Select One Appliance Automotive Medical Military TeleComm Other

Application

Select One Wire Harness Cable Assembly Flat Flex Cable Assembly Over-Molding Discrete Wire Lead Other

Annual Usage

Additional Comments

Special Requirements ( UL, MIL, etc. )

Target Price

 Bid Date Due

Note: MJM can quote from any one of the following: detailed description, sample part or print. In order for MJM to provide the most competitive quote possible, please e-mail an image file as an attachment to sales@mjmindustries.com. If a digital rendering is not available, please fax or mail us a copy of the print.