BRIM ELECTRONICS, INC.
120 HOME PLACE    LODI, NJ 07644
      TEL:201-796-2886        FAX:973-778-2792

E-MAIL: PLEASE PROVIDE THE FOLLOWING INFORMATION:

COMPANY NAME                                              YOUR NAME

FULL COMPANY ADDRESS

TEL.#:                                                                  FAX #:

YOUR MESSAGE:

THEN E-MAIL TO: info@brimelectronics.com