Email: contact@nancylitchfielduv.com.au Ph: 61 - 03 9727 0977   Fax: 61 - 03 9727 0277

	Lamp Quote Request Form
	To help us identify the correct lamp you require, please submit as much of the information below as possible. A few digital photographs showing different angles of the lamp you require would be helpful.
	What is the Lamp Used for ?
	Lamp Manufacturers Name ?
	Lamp Ref./Part Number ?
	Name of Equipment Lamp used in ?
	Other Identifying Marks/Information ?
	Lamp Voltage ?
	Lamp Wattage ?
	Lamp Amps ?
	Lamp Total Length (tip to tip) ?
	Lamp Diameter ?
	Lamp Type ?	Fluorescent Germicidal Incandescent Halogen Deuterium Other
	Lamp Shape ?	Round Tubular Pear Shape Other
	Lamp Base Type ?	Single contact bayonet Two pin Medium screw Candelabra Other
	Additional Information ?
	Your Name ?
	Title ?
	Company Name ?
	Company Mailing Address ?
	Phone Number ?
	Fax Number ?
	Email Address ?
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