Please use this form to submit a request for sample, email our sales
department, or call us at (800) 846-6777.
THIS FORM IS FOR ENGINEERING PROTOTYPES OF PRINTED CIRCUIT TERMINAL BLOCKS ONLY.
WE DO NOT SAMPLE OUR MINI SCREWDRIVER.
FREE MINI SCREWDRIVER AVAILABLE WITH $25.00 ORDER ONLY.

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**First Name:    
**Last Name:    
**Company:    

**SHIP TO Address,
including City, State, Zip:

    

**SHIPPING METHOD:
If other than UPS Ground/Surface,
please provide your UPS or FEDEX
Account Number

    
Email Address:    
**Phone:    
**Qty/Part Number(s) and notes:    

Please check here if you would like us to contact you with a quotation for this product.
Please check here if you would like a copy of our catalog sent with sample.


   
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EuroComp, Inc.
1001 Brioso Drive, Costa Mesa, CA 92627
(800) 846-6777, Fax (949) 650-2992
Located in Southern California in Orange County
Between San Diego and Los Angeles County
www.eurocomp.net
©2003, EuroComp Incorporated

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