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Request Information — A Customized Solution is just a Click Away

At Nielsen Sessions, we're committed to providing you with the solution tailored to your specific needs. Please fill out the request form below, providing as much information as you can, and we'll get back to you shortly.

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Customer Information

*	Company:
	Sales Rep:
	Engineering Contact:
	Purchasing Contact:
*	Address:
*	Phone:
	Fax:
*	City:
*	State:
*	ZIP:
*	Email:
	End User:
	Location:

What?, How Many?, How Much?

Describe Application: (Please forward sketches, drawings or customers actual product for better application understanding)

	New Product		Target Price Range:		Qty:
	Modified Product		Target Price Range:		Qty:
	Existing Product		Current Cost:		Qty:
			Current Source:

Quantities to Quote:		Release Requirements:
Qty Samples Req'd:		Date Samples Required:
1st Year EAU:		Ongoing Years EAU:

Customer Requirements/Specifications

(Check box and describe if applicable)

	Life Cycle Requirement		needwant
	Working Load Requirement		needwant
	Flushness/Envelope Constraints		needwant
	Pad-Lockable/Secondary Catch		needwant
	Temperature Range		needwant
	Corrosion Resistance		needwant
	Vibration/Oscillation		needwant
	Special Mounting/Installation		needwant
	Special Aesthetics/Color/Finish		needwant
	Special Quality Specs/Certs		needwant
	Special Packaging Requirements		needwant
	Other		needwant