Product Request

Please use our convenient request form to contact us for additional information about our products and services.

Use the convenient REORDER section of this form to expedite a previous order.

Your Name:

Company Name:

Street Address:

P.O. Box:

City:

State:

Country:

Email Address:

Phone Number:

Fax Number:

Product Interest:

[Please check the appropriate box/s]

	Electronic			Components
	Wire Products			Automotive Parts
	Clean Room Supplies

Other:

Comments/Questions:

REORDER FORM:

Please complete the information below and we will be happy to process your order:

Company Name:
Your Name:
Purchase Order #:
Phone Number:
Description:
Quantity:
Requested Delivery Date:
Additional Information:

TLC GEL-TRON International Corporation
1357 Suffield Street · P.O. Box 216
Agawam, MA 01001-0216
In the U.S.:
     Telephone: 413-789-1780
     Fax:: 413-789-3140
In the U.K.:
     Telephone: 44 (0) 1294276330
     Fax: 44 (0) 1294272991

Website Design by DSI Marketing