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Please answer all questions completely.
     Customer: 
      Contact: 
      Address: 
         City:  State/Prov: 
       Zip/PC:  Country: 
        Phone:   FAX: 

 Submitted by: 
      Company: 
        Email: 

       Part #:   Quantity:  Target Price: 

      Primary:  Volts:  Freq:  Hz
 Secondary #1:  Volts:  Amps:  Type/Rectifier/Filter 
 Secondary #2:  Volts:  Amps:  Type/Rectifier/Filter 
 Secondary #3:  Volts:  Amps:  Type/Rectifier/Filter 

    Rectifier: FWB=Full Wave Bridge  FWCT=Full Wave Center Tap  DCR=Dual Complimentary
       Filter: C=Capacitor Input L=Inductor Input

      Primary:  Secondary: 
     Mounting:     Series: 

     Max Size: 
       Length:  Width:  Height: 
  
Application: 

  Additional comments:
  

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