*Name
Company
*Address
*City
*State/Province		Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Fdr. States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
*Zip
*Telephone
Fax
*E-mail
Services Required
1. Automation equipment and related services:
	Engineering Services (Mechanical/Electrical) Custom Machine Design Controls design / programming Machine Assembly Services (wiring, pneumatics, hydraulics, etc.) Frame fabrication (machining, welding, etc.) Prototype Design/Build
2. CNC Machining Services
	Metal/Plastic Components Prototypes Other
3. Contract Manufacturing
	Assembly Packaging Wedling Marking Other
Comments:
Attachments		(CAD, Prints, etc.)
*=Required