(print off form, fill out, and FAX (or mail) to XYTEK)

Manufacture:  ________________________, Model:  ____________

Description:  __________________________________________ ____________________________________________________

Quantity:  _________, Age:  __________, Condition:  __________

Location:  ____________________________________________

Extras and Accessories:  ________________________________ ____________________________________________________

When Needed:  _______________________________________

Company Name:  ______________________________________

Contact Person:  _______________________________________

Street Address:  _______________________________________

City:  ___________________, State:  _________, Zip:  _________

Country:  _____________________________________________

Voice Phone (include area code):  ____________________________

FAX (include area code):  ___________________________________

Email Address:  ________________________________________

XYTEK FAX Number:    (313) 838-3960

Mailing Address: XYTEK Industries,
19431 West Davison, Detroit, MI 48223