Required Fields are in YELLOW

~ Contact Information ~
Your Name:
Position:
Your Company:
Address1:
Address2:
City:
State/Province:
Zip code
Country:
Phone Number:
Fax Number:
E-mail Address:
Your Web URL:
~ Specifications ~
This Request is For: A Purchase Order. A Price Quote. A Specifications Change Order. Customer's Part or Drawing Reference #: Initial Quantity: Projected Annual Usage: Select One: We are sending or have sent a drawing. We are sending or have sent a sample. Use Specifications Below. Check All Approvals Required: UL CSA Other: Describe Your Application:
~ Cord ~
Wire Type: Wire gauge (AWG): Temperature Rating: Color: Number of Conductors: Special Requirement: Select One. Color Code Hot Neutral Ground N.A. Black White Green ICC Brown Blue Grn./Yel. Strain Relief: Overall Length:
~ Male End ~
Plug Style Number if Applicable: If Hardwired: Conductor Length Hot: Conductor Length Neutral: Conductor Length Ground: Strip Length: Select One: Blunt Cut. Remove Outer Jacket. Remove Outer Jacket and Strip. Conductors Twisted Only. Conductors Twisted and Tip Tinned. Conductors Twisted and Tinned. Describe Terminals if Applicable:
~ Female End ~
Connector Style Number if Applicable: If Hardwired: Conductor Length Hot: Conductor Length Neutral: Conductor Length Ground: Strip Length: Select One: Blunt Cut. Remove Outer Jacket. Remove Outer Jacket and Strip. Conductors Twisted Only. Conductors Twisted and Tip Tinned. Conductors Twisted and Tinned. Describe Terminals if Applicable:
~ Packaging ~
Packaged in Bulk. Coil Tie. Twist Tie Hank. Self-secured Hank. For Hank Packaging Please Specify: Cap: Body: Free End:
If you know the person you would like to contact:
Special Requirements:
Comments and Questions:
Submitted By:

ELECTRI-CORD Manufacturing Company
312 East Main Street
Westfield, PA. 16950
Telephone: 814-367-2265 ~ Fax: 814-367-2314
Since 1946

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