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Sample Request Form

Fill out form below to submit a sample request.
*All below fields marked with a red asterisk are mandatory to process sample requests.

Customer Information
(If you are the Distributor please list yourself as the customer.)
*Customer Name:  
*Contact Name:  
*Contact Title:  
*Contact Email Address:  
*Contact Phone #:  
*Contact Fax #:  

End Customer Information
(If you are the distributor please list your customer as the end customer.)
*End Customer:  
Contact Name:
Contact Phone #:

Ship to Address
*Company Name:  
*Contact Name:  
*Street:  
*City:  
*State/Province:  
Zip Code:  
*Country:  
*Telephone #:  

Line Detail Information
*Greenliant Part Number: Revision: *Quantity:
   
   
   
   

*Request Date:  
*Engineering Samples Ok?:
*Program Name:  
*Production Date:  
*App. Code:
For App. Codes
Click here [XLS]		  
*Estimated Annual Usage:  
Competitor Name:

Prototype Data:
Anticipated ASP $$:
Chipsets Used:
*Is This Project - MNC/BNC, Own Design, or Joint Design:  

Line Note (optional):

*Business Justification:

 
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