Date*

Account Manager*

Factory Marketing Manager*

Factory Sales Rep Name*

Distributor Sales Rep Name*

Customer Name*

Customer Location*

Customer Contacts(Eng & Purchasing) & Title*

Program Name*

Application*

Quote Due Back Date*

Part Number(s)*

Competition and Parts Numbers*

Annual Quantity*

Number of Years*

Total Value*

Target ASP*

Sample Date*

Purchase Order Date*

Production Start Date and Forecast*

Is SEMICOA currently listed as a qualified supplier*

If NO, what is required to become qualified and how long with the qualification procedure take?

Has the customer purchased this device(s) in the past?*