Luscombe Engineering

central southwest

contact

product line

Astec - Registration Form

	* - required fields

Distributor & Contact Information
*Distributor:

*Name:
*Phone:
*Email:

Customer Contact Information
*Customer Name ::
Email:
*Address ::
Address ::
*City ::
*Zip ::
*State ::
*Phone:

*Buyer / Engineer Name ::

Program Information
*Program Name :
*Application ::
*Evaluation Required Date :
*Program Production Date :
*Program Life (in years):
*CM:

Part Number (1) & Pricing (Competition data required for Special Pricing, otherwise list as "n/a")
*Astec P/N (1) :
*Target Selling Price :
*Target Cost :
*Competition:
*Competition Part Number:

Part Number (2) & Pricing (Competition data required for Special Pricing, otherwise list as "n/a")
Astec P/N (2) :
Target Selling Price :
Target Cost :
Competition:
Competition Part Number:

Part Number (3) & Pricing (Competition data required for Special Pricing, otherwise list as "n/a")
Astec P/N (3) :
Target Selling Price :
Target Cost :
Competition:
Competition Part Number:

Qty Information
*1st Year Qty :
*2nd Year Qty :
*3rd Year Qty :

Comments
Notes / Comments :