Sample Request Form

To order by mail: On-Shore Technology, Inc. 1917 W. 3rd Street Tempe, AZ 85281	To order by phone: Phone: (480) 921-3000 Fax: (480) 968-4444
Please use the form below to receive samples of On-Shore Technology products. You will be contacted with confirmation and availability of your sample request.

All fields with a * are required.

Order Samples

Sample 1

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Sample 2

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Sample 3

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Sample 4

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Sample 5

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Sample 6

Part #:

Qty.:

Est. Annual Qty.:

Target Price:

Please enter information about the recipient of these samples:

First Name: *

Last Name: *

Company Name: *

Title: *

Alternate Contact

First Name:

Last Name:

Address 1: *

Address 2:

City: *

State/Province: *

Postal code: *

Country: *

Phone Number: *

Fax Number:

E-Mail Address: *

Project:

Catalog Request

Please send me (Interconnect):

Please send me (Terminal Block):

Comments: