First Name:

Last Name:

Your email:

Company:

Address:

Address 2:

City:

State:

Zip:

Product Model No:

Serial No.:

Purchase Date:

Primary use for product:
ProfessionalPersonalEducation

Principal type of products manufactured or service performed by your firm:

Industry:

Any other Roper Whitney, Tennsmith, Pexto, Connecticut etc. products in use at your facility:

Determining factor for purchase:
PriceQualityFeaturesParts AvailabilityReputation/BrandAvailabilitySalespersonCountry of OriginFinancingWarranty

How was this item brought to your attention:
Trade ShowWebsiteSocial MediaDealer RecommendationOther