Please complete this form in full

Name:_____________________________________ Date:___________________

Email:______________________________________________________________

Company:__________________________________________________________

Address:___________________________________________________________

City:__________________________ State:__________ Zip:__________

Telephone:__________________________ Fax:___________________________

Project Name:_______________________________________________

Is this project funded?   No_____     Yes_____          Budget:  $______________

Projected purchase date:_______________________

Currently using robots?  No_____      Yes_____

____________________________________________________________________

Robots currently interested in:

Arc Welding_________                                         Assembly_________

Coating_________                                               Dispensing_________

Material Cutting_________                      Material Handling_________

Material Removal_________                          Spot Welding_________

Other_________

____________________________________________________________________

Please fax completed form to 510-895-9843