MicroMex Information Request Form

Please fill out and submit the following information:

Name:                  Title:

Company Name:

Address1:

Address2:

City:

State:

Zip:

Telephone:             Fax:

E-mail:                Web Site:

Select the service(s) you are interested:

Connector Assembly

Fiberglass (at our sister company located in Guadalajara, Jalisco)

Packaging

Mechanical Assembly

Refurbishing

Sorting

SMT Assembly

Through-Hole Assembly

Transformer Assembly

Wiring Harness Assembly

Other

Product/Project:

How did you hear about us?

Please give us a short description of your product(s)/company:

Thanks for contacting MicroMex, Inc.

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