Name:	
Company:	
Address:	
Address:	
City:	
State:	
Zip:	
Phone:	
Fax:	
e-mail:	

Please provide the following specifications for your keypad:

Estimated Annual Qty:	
Number of Material Colors:	
Number of Printing Colors:	
Conductive Contact Type:		Gold	Silver	Carbon	Low Resistance Ink	None
Material Durometer of Keys
(choose 2 if dual durometer required):	50°	60°	70°	80°

Add SealPlast Protective Coating?	Matte	Glossy	None

Please provide a brief description of your application and any other information about your keypad:


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