Ensat, Clifa Request Form

Your Name: Title : Company name: Street address: Mail stop (If required): City: State/Province: Zip/Postal Code: Country (Only if not USA): Phone number: Extension no.: Fax number: E-mail address: (We can only acknowledge your request by e-mail if you have listed an e-mail address.) Send Me Information On: Fasteners for Metal Fasteners for Plastics Fasteners for Wood Fasteners for Thin Sheet Metal Whole Product Line Please Send Me Product Samples (Qualified customers only.) Your web page address (URL)*: * Optional response Would you like to be contacted by phone? Yes No Would you like to open a new account? (We will fax or e-mail a credit application form) Yes No Into what category would your requested application fit? OEM (Original Equipment Manufacturer) MRO (Maintenance or Repair Operation) DISTRIBUTOR (of Industrial supplies) GOVERNMENT (federal, state, or local) END USER Please enter any RFQ's/Comments/Questions or specific requests here: Please do NOT press the 'SEND' button more than once. Please be patient after pressing the 'SEND' button. It may take a short while before your submission is acknowledged.