SPECIAL LENGTH RETRACTILE CORDS AVAILABLE ON REQUEST ON ALL OUR STOCK CORDS. TO ORDER: Fill in the necessary information and click the SUBMIT button on the bottom of the form.

	Product on which retractile cord is to be used:
	Length and type of cord now being used or length to which new cord should extend:
	Length Type
	Appliance or equipment rating (if motor drive, give horsepower):
	Type of retractile cord desired: (check one) Power or Communication
	Jacket material required: (check one)Neoprene Rubber PVC Urethane
	Number of conductors:
	Gauge and type of conductors:
	(check one)  Stranded   Copper  Tinsel
	Shielding requirements: (check one) Shielded Unshielded
	Approximate annual requirements:
	Fill in requirements for A thru E. If possible, mail us a sample of cord to be duplicated.
	Retracted to extended length:
	Cordage diameter and coil O.D.:
	Minimum length of ends with jacket on it:
	Length of insulated conductors (outer jacket removed):
	Length of conductor without insulation (insulation strip):
	If conductor is twisted and/or tinned, specify for each:
	Terminals?:
	Strain relief requirement?:
	Company Name:
	Your Name
	Your Title:
	Mailing/Street Address
	City
	State / Zip:
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	Phone
	Fax Number:
	Email Address:
	Name of Distributor from which you purchase Koiled Kords™: