testing form

*Rep or Dealer Requesting:  

*Requestors Contact:  

ETC Cust #:  

*Requestors Email:  

*ETC Office:  

Additional email contact for loan:  

Ship To:  

Attn:  

*Address:  

*City:  

*State:  

*Postcode:  

*Phone:  

*Email:  

*Project/Site/User:  

Project Registration Number:

Lead Number:  

*Tell Us About Your Demo:  

If Ship To is the same as Project/Site/User please check box.  

Contact:  

Address:  

City:  

State:  

Postcode:  

Phone:  

Email:  

*Date Needed at Location:
(MM/DD/YYYY)

*Return Date (Back at ETC):
(MM/DD/YYYY)

P/N(if known)  

Product Description  

Quantity  

Specific Instructions / Notes: