Your Name:
Company Name:
Street Address:
City:
State:
Zip Code:
Country:
Voice Phone Number:
FAX Number:
Email Address:
Application:	Select One Please Invoice Canceling Mail Receipting Source Document Marking Coupon Book Canceling General Document Marking Dating Documents X-ray Dating Numbering Other
Have you used a perforator before?	Yes No
How soon are you considering a purchase?	Select One Please Right Away! Within Next 6 Months Not Sure Budget Purposes Only Next Year
How would you be paying for your purchase?	Select One Please Purchase Order Cash Wire Transfer (EFT) Company Check Not Sure Credit Card
Will you require the DATE?	Yes No
If you require the DATE, it is normally done with 6 digits and is ALWAYS the second line of perforation. It can ONLY be changed manually, but it is very simple to do.
Will you require any inscription for the FIRST line? If yes, what?	No inscription on first line PAID REC'D VOID CANCL'D Other
If "Other", what do you want to have there?
Will you want any inscription in the THIRD line? If yes, what?
Do you need the FIRST line to be changeable?	Yes No
If Yes, what do you need it to say?
If this machine is for a NUMBERING application, other than the date, how many digits do you need?
Is the address above where you would be having the perforator shipped to?	Yes No
How many units are you looking to purchase?	Select One Please 1 2 3 4 5 6-9 10+
What is your POWER requirement?	Select One Please 120 VAC 60 Hz 230 VAC 50 Hz 230 VAC 60 Hz
Please enter any other specific questions or requirements you have:
Thank you for your time. We will be get back to you just as soon as possible!
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