To best determine your price structure, please take a moment to answer the following questions.  
 
   


 

  *E-mail
 
  *Password
   (4 to 12 charactors)
  
  *RE-ENTER Password
  
  *Fisrt Name
  
  *Last Name
  
  *Phone
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  *Company Name
  
  *Business/ Billing
    Address
  Address1
  Address2
  City
  Province/ State
  
  Zip
  Country   
  *1. Company Category
 
  *2. Industry
 
  *3. Type of Business
 
  *4. Products in which you
        are interested
  Primary:  
  Secondary 1:
  Secondary 2:


  *Is this your 1st timepurchase of Fuji Electric
    Distribution and Control products?

    If not,where did you previously purchase the products?
  Yes No
 
   Provide names of the company:
   
  *Please indicate your order type.
  One Time Small MRO Use
  One Time Project Use
  Continuing Business
  *Please provide your
 estimated annual usage.
 
  *Is credit card payment acceptable?
  Yes   No. (NET 30 DAYS Prefer)
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