Ohmite Mfg. Co. 1600 Golf Rd., Suite 850 Rolling Meadows, IL 60008 Tel: 1-866-9-OHMITE (1-866-964-6483) Int'l: 1-847-258-0300 Fax: 1-847-574-7522 info@ohmite.com www.ohmite.com

Use this form to request samples from Ohmite: Ohmite Part Number/Series Ohm Value or Any Value Wattage or Any Value Tolerance or Any Value Additional Note Estimated Annual Usage* -- Less than 100 101-1000 1001-5000 5001-10,000 Over 10,000 Name* Title Company* Address line 1* Address line 2 City* State* -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY -- Canada: AB BC MB NB NF NS NT ON PE QC SK YT Postal Code* Country* Phone Number* Fax Number E-Mail Address* *Required

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