<p> CUSTOM TAG REQUEST FORM Customer: Contact: Address 1: Phone No: Address 2: Email: </p><p>City, State, Zip: Date Submitted: Application Description:</p><p>Frequency is Required? Choose Option Data Capacity: Select From Pull-Down</p><p>Other Frequency: Other Data Capacity: </p><p>What Reader is the Tag to be Used With? </p><p>What Size Antenna is to be Used with the Reader? Specify Dimensions and Reader Power Level if Known Tag to be Mounted Near Metal? Choose Antenna to be Mounted Near Metal? Choose If YES, How the Tag is Intended to be If YES, How is the Antenna Intended to be Mounted? Mounted? Qty of Tags are Required? Specify Quantiy Required R/W Range? Specify Range</p><p>Tag Max. Temperatured: Temperature in C Tag Min. Temperature: Temperature in C If the Tags are to be Used in Extreme Temperatures, Describe the Thermal Cycle Profile and Minimum Number of Cycles Tags Must Survive Define Other Environmental Conditions that the Tags Must Survive, such as Chemicals, Vibration, Impact, Pressure, etc. Please Describe the Desired Form Factor for the Tags (Labels, PCB, Molded, etc.) Please Provide Dimension (L x W x H; or Diameter and Thickness). Specify if a Mounting Hole is Need (and Size) or Adhesive or Other Means of Attachment. What is the Target Cost? When are Tags Needed? Qualification Period Before Re-Order? Please Email the Completed Form to: [email protected] and include any additional information such as drawings, datasheets for chemicals tags will be used with.</p><p>© 2010 WAVE LOGIC INC, 175 EL PUEBL0 RD., UNIT 28, SCOTTS VALLEY, CA 95066 (831) 515 5699 www.wave-logic.com</p>