Special Request
Fax to:
Optimus Fax No. 901-794-3884
Company Name________________________________________ Date___________________
Address______________________________________________

Phone__________________
City, State, Zip_________________________________________ Fax____________________
Order Placed by___________________ PO No_______________ Opt. Cust No.___________
I need a Part I can't find in your Catalog
Qty.___________ Mfg.________________
Mfg. Part No._________________________

Description___________________________

____________________________________

This part of what Product?______________

__________________________________
OFFICE USE ONLY
Attention ____________________________
Part Available_________________________
Price________________________________
Optimus item No.______________________
Stock Item or Special Order______________
Lead Time___________________________
Are these items returnable Y__ N__
Comments____________________________
____________________________________
Qty.___________ Mfg._______________
Mfg. Part No.________________________

Description__________________________

__________________________________

This part of what Product?______________

__________________________________
OFFICE USE ONLY
Attention _____________________________
Part Available_________________________
Price________________________________
Optimus item No.______________________
Stock Item or Special Order______________
Lead Time___________________________
Are these items returnable Y__ N__
Comments____________________________
____________________________________