Please provide the following contact information:

First name
Last name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Project name and/or brief description:
Is it a color application (using a color camera)?	Yes   No
Preferred light source (e.g. LED/FO/FL):
Power source available? - If yes, specify AC/DC, amperage:
Continuous or strobed application?	No preference Continuous Strobed
Minimum clearance (part to bottom of light, in mm's):
Maximum light size (L x W x H, in mm's)

Vision system brand/model:	Please choose one... Acuity CiMatrix Banner Cognex Coreco DVT Integral Vision Keyence Matrox National Instrument NeuroCheck Omron PPT Sharp Siemens Other
Camera brand/model:
Lens (brand, mm, F-Stop):
FOV (mm):
Is the FOV and focal distance fixed?	Yes No
Distance from part to bottom of lens (mm):

Can you provide samples for us to image?	Yes No
Do you need them returned?	Yes No
Any environmental factors (oil, heat, moisture, etc) to consider?	Yes No
If yes - briefly describe
Target market(s):	Please indicate applicable markets... Aerospace Electronics Automotive Semiconductor Pharmaceutical Packaging Mail-Sorting Warehousing Other
Is this a new system in development or one already on the market:	New On Market
Potential number of lighting or imaging units required annually:
Required delivery date for beta units:
Date of Product introduction:
Target price per unit:
Additional comments:

How did you hear of NERLITE?

Choose one... Distributor Web Search Trade Show Publication  Name: