Qualectron -Information Request Form

M i O echan t

Company:
Name:	Title:
Address:
City:	State: Zip code: Country:
Tel:	Ext.#: Fax:
Email:
Industry:	Products:

	Product(s) of Interest:
	X-Ray Machine	3D SPI	AOI
	XSCAN-A100	3D Pro 2200 SPI Offline-Line	ESV-2240 AOI Off-Line
	XSCAN-H100-OCT	3D Master 3000 SPI Offline-Line	Focus-5500DT AOI Off-Line
		3D Pro 3200 SPI In-Line	Focus-5000GX AOI In-Line

	In-Circuit Tester	Functional Tester	Mechanical Fixture Boxes
	QS-8200 Compact	FX-210/211 FX-212 FX-300	SF Series
	QS-8200T Off-Line	FX-320 FX-360 FX-400P	DF Series
	QS-8200S In-Line	FX-500 FX-510 FX-600
		FX-610 FX-620 FX-630
		FX-700 FX-910 ATS Builder

	Testing Services	Other Products
	Flying Probe Testing Service	Test Probes
	Boundary Scan Testing Service	Other:
	Test Fixture

	Actions:
	Send product brochure Request sales representative to call

	Purhcase Consideration:
	Immediately Within 1 month Within 3 months Within 6 months More than 6 months Collect information

	How did you hear about Qualectron Systems?
	Web Site Google Search Circuitnet US Tech Email Marketing
	Trade Show: Referral by: Other:

	Comment:

Information Request Form