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Ship to Company Name: *  Shipping Addr. 1: *  We cannot ship to a PO Box Shipping Addr. 2: City: *  Country: (if not USA) AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA ASCENSION ISLAND AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIIBOUTI DOMINICA DOMINICAN REPUBLIC EAST TIMOR ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FAEROE ISLANDS FALKLAND ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GILBRATAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD AND MCDONALD ISLANDS HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISLE OF MAN ISRAEL ITALY IVORY COAST JAMAICA JAPAN JAZAJGSTAB JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTH KOREA NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIA RWANDA SAINT BARTHELEMY SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT VINCENT AND THE GRENADINES SAIPAN SAMOA SAN MARINO SAOTOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAK REPUBLIC SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SOUTH KOREA SPAIN SRI LANKA ST PIERRE & MIQUELON ST. HELENA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND TOGO TOKELAU TONGA TRINIDAD TUNISIA TURKEY TURKMENISTAN TURKS & CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM VIRGIN ISLANDS (BRITISH) VIRGIN ISLANDS (US) WALLIS & FUTUNA ISLANDS WESTERN SAHARA YEMEN ARAB REPUBLIC YUGOSLAVIA ZAIRE ZAMBIA ZIMBABWE State: ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND Saint Kitts and Nevis SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS TUNISIA UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING * Zip/Postal Code: *  Attention First Name: *  Attention Last Name: *  Attention Telephone: *  Attention Fax: Attention E-mail: *  Enter only if different than "Attention" information - Requested By First Name: Requested By Last Name: End Customer and Location information required if shipping to Samtec Disty or Rep Address - End Customer Info: Please make sure to include both Customer Name AND Location information.

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Samtec Parts Item #1: Qty: 2SN 6QCD 6QDP 6QDPS ATEP AW BBD BBL BBS BCS BDL BHS BKS BKT BSE BSH BSS BSW BTE BTH BTS CES CFT CLE CLM CLP CLT DEC8 DPAF DPAM DW DWM EEDP EHF EHT EJH EPLSP EQCD EQDP EQRF EQSD ERCD ERCDA ERDP ERF8 ERF8-RA ERM8 ESD ESQ ESQT ESRF ESS ESW EW FC1 FFMD FFSD FHP FHSC FJH FLE FOLC FSI FTE FTMH FTR FTSH FW FWJ GFZ HBCD HDAF HDAM HDMI HDWM HFWJ HLE HLST HMTMS HMTSW HPDPI HPF HPFC HPLSP HPM HPMC HPSTP HPW HQCD HQDP HSS HTMS HTS HTSS HTST HTSW HW ICO IDMD IDMS IDSD IDSS IPBD IPBS IPBT IPD1 IPL1 IPS1 IPT1 ISDF LCW LS2 LSH LSS LST LTH LTMM MB1 MCX MCX7 MCX-EM MCX-SM MCX-TH MEC1 MEC1-EM MEC1-RA MECT MH081 MH113 MICD MIS MIT MLE MMCX MMCX-EM MMCX-SM MMCX-TH MMS MMSD MMT MNT MOLC MPS MPSC MPT MPTC MTLW MTMM MTMS MTSW MUSB MW OPP PCIE PCIEC PEC PES PESC PET PETC PGP PLCC PMSD PMSS PTF PTHF PTT Q2DA QFS QFS-DP QFS-EM QFS-RA QFSS QFSS-DP QMS QMS-DP QMS-EM QMS-RA QMSS QMSS-DP QSE QSE-DP QSE-DP-EM QSE-EM QSH QSH-DP QSS QSS-EM QSS-RA QTE QTE-DP QTE-DP-EM QTE-EM QTH QTH-DP QTS QTS-DP QTS-EM QTS-RA RF058 RF174 RF178 RF179 RF316 ROLC RSM RU8 SAL1 SCP1 SCP2 SCP3 SCPE SCPU SCR1 SCR2 SCR3 SCRES SCRUS SCTP SD SDL SEAF SEAM SEI SEL SEM SEML SFC SFLX SFM SFMC SFMH SFML SFMX SIB SL SLM SLW SMB5 SMB7H SMH SMM SMS SNM SNT SOLC SQCD SQT SQW SS SS4 SSM SSQ SSW ST4 STMM TCMD TCSD TD TEM TFM TFML THSC TLE TLSD TLW TML TMM TMMH TMMS TMS TNC TOLC TS TSDF TSH TSM TSS TSSH TST TSW TW USBC USBR USBR-A USBR-B VHDCP VHDCR VPDP VPLSP VPSTP ZF1 ZF5 ZLTMM ZML ZSS ZST ZSTMM ZW Item #2: Qty: 2SN 6QCD 6QDP 6QDPS ATEP AW BBD BBL BBS BCS BDL BHS BKS BKT BSE BSH BSS BSW BTE BTH BTS CES CFT CLE CLM CLP CLT DEC8 DPAF DPAM DW DWM EEDP EHF EHT EJH EPLSP EQCD EQDP EQRF EQSD ERCD ERCDA ERDP ERF8 ERF8-RA ERM8 ESD ESQ ESQT ESRF ESS ESW EW FC1 FFMD FFSD FHP FHSC FJH FLE FOLC FSI FTE FTMH FTR FTSH FW FWJ GFZ HBCD HDAF HDAM HDMI HDWM HFWJ HLE HLST HMTMS HMTSW HPDPI HPF HPFC HPLSP HPM HPMC HPSTP HPW HQCD HQDP HSS HTMS HTS HTSS HTST HTSW HW ICO IDMD IDMS IDSD IDSS IPBD IPBS IPBT IPD1 IPL1 IPS1 IPT1 ISDF LCW LS2 LSH LSS LST LTH LTMM MB1 MCX MCX7 MCX-EM MCX-SM MCX-TH MEC1 MEC1-EM MEC1-RA MECT MH081 MH113 MICD MIS MIT MLE MMCX MMCX-EM MMCX-SM MMCX-TH MMS MMSD MMT MNT MOLC MPS MPSC MPT MPTC MTLW MTMM MTMS MTSW MUSB MW OPP PCIE PCIEC PEC PES PESC PET PETC PGP PLCC PMSD PMSS PTF PTHF PTT Q2DA QFS QFS-DP QFS-EM QFS-RA QFSS QFSS-DP QMS QMS-DP QMS-EM QMS-RA QMSS QMSS-DP QSE QSE-DP QSE-DP-EM QSE-EM QSH QSH-DP QSS QSS-EM QSS-RA QTE QTE-DP QTE-DP-EM QTE-EM QTH QTH-DP QTS QTS-DP QTS-EM QTS-RA RF058 RF174 RF178 RF179 RF316 ROLC RSM RU8 SAL1 SCP1 SCP2 SCP3 SCPE SCPU SCR1 SCR2 SCR3 SCRES SCRUS SCTP SD SDL SEAF SEAM SEI SEL SEM SEML SFC SFLX SFM SFMC SFMH SFML SFMX SIB SL SLM SLW SMB5 SMB7H SMH SMM SMS SNM SNT SOLC SQCD SQT SQW SS SS4 SSM SSQ SSW ST4 STMM TCMD TCSD TD TEM TFM TFML THSC TLE TLSD TLW TML TMM TMMH TMMS TMS TNC TOLC TS TSDF TSH TSM TSS TSSH TST TSW TW USBC USBR USBR-A USBR-B VHDCP VHDCR VPDP VPLSP VPSTP ZF1 ZF5 ZLTMM ZML ZSS ZST ZSTMM ZW Item #3: Qty: 2SN 6QCD 6QDP 6QDPS ATEP AW BBD BBL BBS BCS BDL BHS BKS BKT BSE BSH BSS BSW BTE BTH BTS CES CFT CLE CLM CLP CLT DEC8 DPAF DPAM DW DWM EEDP EHF EHT EJH EPLSP EQCD EQDP EQRF EQSD ERCD ERCDA ERDP ERF8 ERF8-RA ERM8 ESD ESQ ESQT ESRF ESS ESW EW FC1 FFMD FFSD FHP FHSC FJH FLE FOLC FSI FTE FTMH FTR FTSH FW FWJ GFZ HBCD HDAF HDAM HDMI HDWM HFWJ HLE HLST HMTMS HMTSW HPDPI HPF HPFC HPLSP HPM HPMC HPSTP HPW HQCD HQDP HSS HTMS HTS HTSS HTST HTSW HW ICO IDMD IDMS IDSD IDSS IPBD IPBS IPBT IPD1 IPL1 IPS1 IPT1 ISDF LCW LS2 LSH LSS LST LTH LTMM MB1 MCX MCX7 MCX-EM MCX-SM MCX-TH MEC1 MEC1-EM MEC1-RA MECT MH081 MH113 MICD MIS MIT MLE MMCX MMCX-EM MMCX-SM MMCX-TH MMS MMSD MMT MNT MOLC MPS MPSC MPT MPTC MTLW MTMM MTMS MTSW MUSB MW OPP PCIE PCIEC PEC PES PESC PET PETC PGP PLCC PMSD PMSS PTF PTHF PTT Q2DA QFS QFS-DP QFS-EM QFS-RA QFSS QFSS-DP QMS QMS-DP QMS-EM QMS-RA QMSS QMSS-DP QSE QSE-DP QSE-DP-EM QSE-EM QSH QSH-DP QSS QSS-EM QSS-RA QTE QTE-DP QTE-DP-EM QTE-EM QTH QTH-DP QTS QTS-DP QTS-EM QTS-RA RF058 RF174 RF178 RF179 RF316 ROLC RSM RU8 SAL1 SCP1 SCP2 SCP3 SCPE SCPU SCR1 SCR2 SCR3 SCRES SCRUS SCTP SD SDL SEAF SEAM SEI SEL SEM SEML SFC SFLX SFM SFMC SFMH SFML SFMX SIB SL SLM SLW SMB5 SMB7H SMH SMM SMS SNM SNT SOLC SQCD SQT SQW SS SS4 SSM SSQ SSW ST4 STMM TCMD TCSD TD TEM TFM TFML THSC TLE TLSD TLW TML TMM TMMH TMMS TMS TNC TOLC TS TSDF TSH TSM TSS TSSH TST TSW TW USBC USBR USBR-A USBR-B VHDCP VHDCR VPDP VPLSP VPSTP ZF1 ZF5 ZLTMM ZML ZSS ZST ZSTMM ZW Item #4: Qty: 2SN 6QCD 6QDP 6QDPS ATEP AW BBD BBL BBS BCS BDL BHS BKS BKT BSE BSH BSS BSW BTE BTH BTS CES CFT CLE CLM CLP CLT DEC8 DPAF DPAM DW DWM EEDP EHF EHT EJH EPLSP EQCD EQDP EQRF EQSD ERCD ERCDA ERDP ERF8 ERF8-RA ERM8 ESD ESQ ESQT ESRF ESS ESW EW FC1 FFMD FFSD FHP FHSC FJH FLE FOLC FSI FTE FTMH FTR FTSH FW FWJ GFZ HBCD HDAF HDAM HDMI HDWM HFWJ HLE HLST HMTMS HMTSW HPDPI HPF HPFC HPLSP HPM HPMC HPSTP HPW HQCD HQDP HSS HTMS HTS HTSS HTST HTSW HW ICO IDMD IDMS IDSD IDSS IPBD IPBS IPBT IPD1 IPL1 IPS1 IPT1 ISDF LCW LS2 LSH LSS LST LTH LTMM MB1 MCX MCX7 MCX-EM MCX-SM MCX-TH MEC1 MEC1-EM MEC1-RA MECT MH081 MH113 MICD MIS MIT MLE MMCX MMCX-EM MMCX-SM MMCX-TH MMS MMSD MMT MNT MOLC MPS MPSC MPT MPTC MTLW MTMM MTMS MTSW MUSB MW OPP PCIE PCIEC PEC PES PESC PET PETC PGP PLCC PMSD PMSS PTF PTHF PTT Q2DA QFS QFS-DP QFS-EM QFS-RA QFSS QFSS-DP QMS QMS-DP QMS-EM QMS-RA QMSS QMSS-DP QSE QSE-DP QSE-DP-EM QSE-EM QSH QSH-DP QSS QSS-EM QSS-RA QTE QTE-DP QTE-DP-EM QTE-EM QTH QTH-DP QTS QTS-DP QTS-EM QTS-RA RF058 RF174 RF178 RF179 RF316 ROLC RSM RU8 SAL1 SCP1 SCP2 SCP3 SCPE SCPU SCR1 SCR2 SCR3 SCRES SCRUS SCTP SD SDL SEAF SEAM SEI SEL SEM SEML SFC SFLX SFM SFMC SFMH SFML SFMX SIB SL SLM SLW SMB5 SMB7H SMH SMM SMS SNM SNT SOLC SQCD SQT SQW SS SS4 SSM SSQ SSW ST4 STMM TCMD TCSD TD TEM TFM TFML THSC TLE TLSD TLW TML TMM TMMH TMMS TMS TNC TOLC TS TSDF TSH TSM TSS TSSH TST TSW TW USBC USBR USBR-A USBR-B VHDCP VHDCR VPDP VPLSP VPSTP ZF1 ZF5 ZLTMM ZML ZSS ZST ZSTMM ZW Item #5: Qty: 2SN 6QCD 6QDP 6QDPS ATEP AW BBD BBL BBS BCS BDL BHS BKS BKT BSE BSH BSS BSW BTE BTH BTS CES CFT CLE CLM CLP CLT DEC8 DPAF DPAM DW DWM EEDP EHF EHT EJH EPLSP EQCD EQDP EQRF EQSD ERCD ERCDA ERDP ERF8 ERF8-RA ERM8 ESD ESQ ESQT ESRF ESS ESW EW FC1 FFMD FFSD FHP FHSC FJH FLE FOLC FSI FTE FTMH FTR FTSH FW FWJ GFZ HBCD HDAF HDAM HDMI HDWM HFWJ HLE HLST HMTMS HMTSW HPDPI HPF HPFC HPLSP HPM HPMC HPSTP HPW HQCD HQDP HSS HTMS HTS HTSS HTST HTSW HW ICO IDMD IDMS IDSD IDSS IPBD IPBS IPBT IPD1 IPL1 IPS1 IPT1 ISDF LCW LS2 LSH LSS LST LTH LTMM MB1 MCX MCX7 MCX-EM MCX-SM MCX-TH MEC1 MEC1-EM MEC1-RA MECT MH081 MH113 MICD MIS MIT MLE MMCX MMCX-EM MMCX-SM MMCX-TH MMS MMSD MMT MNT MOLC MPS MPSC MPT MPTC MTLW MTMM MTMS MTSW MUSB MW OPP PCIE PCIEC PEC PES PESC PET PETC PGP PLCC PMSD PMSS PTF PTHF PTT Q2DA QFS QFS-DP QFS-EM QFS-RA QFSS QFSS-DP QMS QMS-DP QMS-EM QMS-RA QMSS QMSS-DP QSE QSE-DP QSE-DP-EM QSE-EM QSH QSH-DP QSS QSS-EM QSS-RA QTE QTE-DP QTE-DP-EM QTE-EM QTH QTH-DP QTS QTS-DP QTS-EM QTS-RA RF058 RF174 RF178 RF179 RF316 ROLC RSM RU8 SAL1 SCP1 SCP2 SCP3 SCPE SCPU SCR1 SCR2 SCR3 SCRES SCRUS SCTP SD SDL SEAF SEAM SEI SEL SEM SEML SFC SFLX SFM SFMC SFMH SFML SFMX SIB SL SLM SLW SMB5 SMB7H SMH SMM SMS SNM SNT SOLC SQCD SQT SQW SS SS4 SSM SSQ SSW ST4 STMM TCMD TCSD TD TEM TFM TFML THSC TLE TLSD TLW TML TMM TMMH TMMS TMS TNC TOLC TS TSDF TSH TSM TSS TSSH TST TSW TW USBC USBR USBR-A USBR-B VHDCP VHDCR VPDP VPLSP VPSTP ZF1 ZF5 ZLTMM ZML ZSS ZST ZSTMM ZW Samtec Literature Corporate Profile-A4 06/09 Corporate Profile-US 06/09 Full Line Catalog-A4 05/09 Full Line Catalog-US 05/09 Interconnect Capabilities-A4 07/07 Interconnect Capabilities-US 07/07 Micro Backplane Solutions Guide-A4 06/09 Micro Backplane Solutions Guide-US 06/09 Rugged Interconnect Guide-A4 Rugged Interconnect Guide-US Signal Integrity Handbook 08/07 SiliconBlade Socket Flyer TLS Guide-A4 09/08 TLS Guide-US 09/08 Qty: Corporate Profile-A4 06/09 Corporate Profile-US 06/09 Full Line Catalog-A4 05/09 Full Line Catalog-US 05/09 Interconnect Capabilities-A4 07/07 Interconnect Capabilities-US 07/07 Micro Backplane Solutions Guide-A4 06/09 Micro Backplane Solutions Guide-US 06/09 Rugged Interconnect Guide-A4 Rugged Interconnect Guide-US Signal Integrity Handbook 08/07 SiliconBlade Socket Flyer TLS Guide-A4 09/08 TLS Guide-US 09/08 Qty: Corporate Profile-A4 06/09 Corporate Profile-US 06/09 Full Line Catalog-A4 05/09 Full Line Catalog-US 05/09 Interconnect Capabilities-A4 07/07 Interconnect Capabilities-US 07/07 Micro Backplane Solutions Guide-A4 06/09 Micro Backplane Solutions Guide-US 06/09 Rugged Interconnect Guide-A4 Rugged Interconnect Guide-US Signal Integrity Handbook 08/07 SiliconBlade Socket Flyer TLS Guide-A4 09/08 TLS Guide-US 09/08 Qty: Corporate Profile-A4 06/09 Corporate Profile-US 06/09 Full Line Catalog-A4 05/09 Full Line Catalog-US 05/09 Interconnect Capabilities-A4 07/07 Interconnect Capabilities-US 07/07 Micro Backplane Solutions Guide-A4 06/09 Micro Backplane Solutions Guide-US 06/09 Rugged Interconnect Guide-A4 Rugged Interconnect Guide-US Signal Integrity Handbook 08/07 SiliconBlade Socket Flyer TLS Guide-A4 09/08 TLS Guide-US 09/08 Qty: Corporate Profile-A4 06/09 Corporate Profile-US 06/09 Full Line Catalog-A4 05/09 Full Line Catalog-US 05/09 Interconnect Capabilities-A4 07/07 Interconnect Capabilities-US 07/07 Micro Backplane Solutions Guide-A4 06/09 Micro Backplane Solutions Guide-US 06/09 Rugged Interconnect Guide-A4 Rugged Interconnect Guide-US Signal Integrity Handbook 08/07 SiliconBlade Socket Flyer TLS Guide-A4 09/08 TLS Guide-US 09/08 Qty: Notes: After you have entered all information including the Parts and/or Literature to be Sampled, you must click on the "SUBMIT" button below in order to send your request to us.