Custom Product Request

Looking for customization? No problem! Fill out this form to give us a description of what you are looking for so we can adequately determine the best approach for your project.

Please note:
  • 50% payment in advance is required for custom items.
  • Custom items are non-refundable unless our QA Department determines a manufacturing defect and authorizes the return of the parts.
  • Quotes usually take 1-2 weeks upon receipt of request.
  • Lead times are approximately 10-12 weeks for custom items.

The fields indicated with an asterisk (*) are required; other fields are optional.

Salutation:
 
First Name:*  
  
Last Name:*  
  
Title:*  
  
Company:*  
  
Employer #:
(Tax ID #, or Sales ID #)
  
This is an optional field, however, should you decide to place an order with Qosmedix, a tax ID number is required for US customers.
Address:*  
    
2nd line:
    
3rd line:
    
City:*  
    
Country:*
  
State:*
  
Zip/Postal Code:*  
    
Phone Number:*  
 
Fax Number:  
E-mail Address:*
  
Company Website:
   
Part Number:
   
Minimum Quantity Desired:
Size/Measurements:
Material:
   
Logo Required:
   
Placement of Logo:
   
Color or Pantone/PMS Shade:
   
How would like the item packed?
   
Requests or Comments:*