Requestor
Organization*:
Division:
Shipping address*:
City, State, Zip*:
Point of Contact
Contact name & title*:
Email address*:
Phone number*:	Ext:
Fax number:
General Quote Information
Type of quote needed :	Budgetary  Firm Fixed Price
Special needs :	None  A2LA  ISTA  Expanded Uncertainty
NOTE: Qualtest takes exception to providing Expanded Uncertainty, even when required by the test standard, unless special arrangements are negotiated in advance.
Expected date for the start of testing:
NOTE: Qualtest prefers to have a purchase order at least five days prior to the start of a test to allow for proper contract review, planning and test preparation.   NOTE: With regard to support equipment supplied by the customer, Qualtest assumes responsibility only for equipment needed to satisfy our contract obligations. Any additional equipment brought by the customer is the responsibility of the customer.
Expected number of onsite customer reps/witnesses:
Note: Qualtest offers a customer lounge area equipped with phone, cable TV,  High Speed Internet access, vending machines and free coffee. Copier and fax machines are readily available.  Dial up modem connection can be arranged.
Test Item Identification
Name, P/N, or Model*:
Weight *: Size(LxWxH)*: Quantity*:
Any Additional Descriptive Information (HAZMAT, Fragility, Storage, External Ground Connections, RF Transmit Device, End Item Platform, etc.):
Test Requirements:
Test Requirements*: attached listed below (Test Type, Test Spec, # Test Items, Field Levels, Modulation, etc.)
Test Item Support Requirements
How will the test items interface?  (Distance of cable from test item to support equipment (6 foot minimum required) NA  Customer provided fixture  Qualtest provided Stand-offs and Strap-downs Additional Interface Information:
What are your Ground Plane Requirements? NA  Customer Provided Conductive Table Non-Conductive Table Additional Information:
Electrical / Mechanical needs for Test Item Operation (power / phase / frequency; gas pressure; connectors, etc): NA  Described Below
Responsibility for Test Item Operation: NA  Customer Rep.  Qualtest (requires detailed procedure for quote) Additional information:
Data Documentation Requirements:
Report with data    Certification without data Raw data only   None
NOTE: Qualtest Reports and Certifications attest to the compliant provision of the test environment, but not to the pass/fail status of the test hardware unless special arrangements are negotiated in advance.
Data Documentation Media Preference: Adobe PDF    MS Word (protected)
Data Documentation Delivery Preference: Email    CD    Hard Copy    NOTE: Additional charges apply for CD and Hard Copy deliveries.
Any special needs, comments, or concerns:
Quote Need / Desired Date

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