C & B Sales Associates, LLP

C & B Sales Associates, LLP

Manufacturers' Representatives

INFORMATION REQUEST FORM

First Name: Last Name:

Phone: FAX:

E-Mail:

Company/Agency Name:

Street Address 1:

Street Address 2:

City: State: ZIP:

Product Interest (Please check all that apply):

360 Vision

Armida

ESD

ioimage

Mitsutech

MuxLab

PCSC

Sanyo Security

Southwest Microwave

Tokina

Ultravision

Vitek

Videotec

Please list specific product questions here:

C & B Sales Associates, LLP · 8675 Majors Road · Cumming, GA 30041

Nationwide Toll Free: 866-566-9530 · 770-844-0081 · FAX: 770-844-7961

E-mail: sales@cbsallp.com · Web site: www.cbsallp.com