Welcome to the Lewis Bass International

Date of Request:
Company Name:
Requestors Name:
Company Address:
Suite Number:
City:	State: Zip: Country:

Mail Stop:
E-Mail:
Phone Number:
Fax Number:
Type of Inspection:
Equipment Model:
Tool Serial Number(s):

PRE-INSPECT LOCATION:

City:
State:
Country:

INSPECT LOCATION:

City:
State:
Country:

Will you require an invoice to process your advance payment? Yes No

Purchasing Contact
Name:
Phone Number:
A/P Contact
Name:
Phone Number:

SPECIAL REQUIREMENTS:

Additionally, please provide us with a brief written description or marketing brochure of the
equipment to be evaluated for our review and consideration when creating the proposal

Information being sent to:
Lewis Bass
Phone: (408) 374-4453 • Fax: (408) 374-0295