Company Info:

Company Name: _____________________ Contact Name: ______________________
Phone #: ___________________________ Fax #: _____________________________
Email: _____________________________ Site URL: __________________________

Required information:

Qty: ________
Amps: _________________ Volts: ____________
Overall length: ___________ inches Arc length: _________ inches
Watts per inch: __________ Ozone free? Yes / No

Helpful information:

equipment manufacturer: ___________ Model: ____________________________
Lamp part #: _____________________ Fax to (616) 669-7704
Please identify and check the appropriate end fitting that you require. After filling out this form as completely as possible please fax it to (616) 669-7704. We will keep a record of your order to simplify and speed future orders. If you lamp does not match the above standards we will probably still be able to provide your lamp, though it may be necessary to send us a sketch or a burned lamp to identity the proper type. If you need help just call us at (616) 669-164