EZ Rated Submission Form
Ship (insured) to:  EZ Rated, Inc., 116 Lake Ave., Suite: 200
Yonkers, NY 10703-2710

Ph.: 877.380.9545   Fax: 801.720.7726
email: submission@EZrated.com

Please include this completed form with the evaluation unit(s) or with its packing slip.

Company Submitting Product:	
Primary Contact Name:	
Address 1:	
Address 2:	
City/State/Zip:	
Telephone:	Ext.	 Fax: 	

Evaluation Unit Information:
Please answer the following items of information to help us serve you better.

Submitted Product / Service is:	        A Production Unit
                                                      (Check One)  	        A Pre-production Unit (see below)

Changes to be made to the production units will be:	

	

Other configurations to be offered for this product / service (accessories, spec. variations, etc.):	

Submitted Documentation is:	        Final Documentation
                                                      (Check One)	        Non-Final Documentation (see below)

Changes to be made to the final documentation will be: 	

	

Estimated Annual Production?	units
Estimated Date of Volume Production?____/ ____/	
List Competing Products or Services:	Brand	Model

	

Target Market Description:	

Use a separate sheet of paper if necessary.
Thank You.