Information and Service Request

Request Preliminary Design Review Evaluation, Testing, Report Compliance Report (FDA, CE Marking) UL Classification TUV Certification Other Request (Enter Below)

Other Request

Company Name

Address,

City, State, Zip

Contact Name

Contact Phone No.

Contact Email Address

Equipment Type, Intended Use

Model Name/Number

Electrical Ratings

Communication Ports on Equipment None Ethernet Serial/RS232 USB Telephone Other

Power Supply Type Internal (Transformer) Internal (Switch-mode) External (AC adapter) Other

Enclosure Material Plastic Metal Plastic and Metal Other

Approximate Size/Weight of Equipment Hand-Held Portable <10 lbs Portable >10 lbs Mobile / Cart Stationary / Fixed (>100 lbs)

Additional Information