Custom Application Form

Customer Information Fields with an * require information. *First Name: *Last Name: Company: Title: Address 1: Address 2: City: State: Zip Code: *Phone: Fax: E-Mail:     Application       Requirements Mechanical Type of Scope: Borescope (Rigid) Micro  Fiberscope   Videoscope  Other  Working Length: WL Diameter: Line of Sight: Other: Optical     (Not all should be filled in, just the one(s) that are of primary importance.) Object Distance (OD): to inches  mm Smallest Object to Resolve: at Object Distance inches  mm Resolution Spec: Field of View (FOV): Fixed º  or Variable (Zoom) º   to º Mag Requirement: X  at inches   mm Object Distance Image Orientation: Normal Erect Reverted Erect Normal Inverted Reverted Inverted Other:     Viewing Modes Eyepiece (visual mode): Yes  No Video (video mode): Yes  No     If Yes,   CCD Format: 1/4" 1/3" 2/3"  Other Image Format: V      H    D      Other Photo (photo mode): Yes  No   If Yes, Camera Make                    & Model Simultaneous Multi-mode Viewing: Yes  No If Yes, What Modes? Visual  Video   Photo     Environment Special Requirements (high or low temperature or pressure, gaseous, chemical, radiation):   Lighting: Standard White Light UV Other   Electrical: 115VAC/60Hz  230VAC/50Hz   Switchable  Other