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Title (Mr, Ms, Dr)
Mr
Ms
Dr
Name
*
First
Last
Company
*
Job Title
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
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Cyprus
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Côte d'Ivoire
Denmark
Djibouti
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Dominican Republic
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Eswatini
Ethiopia
Falkland Islands
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Gabon
Gambia
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Germany
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Guyana
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Indonesia
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Iraq
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Italy
Jamaica
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Korea, Republic of
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Virgin Islands, U.S.
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Country
Phone
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Business Informaton
Your Business
Manufacturer
Distributor of parts/supplies
Remanufacturer/recycler of toner cartridges
Research/testing laboratory
Other (Specify Below)
What Type of Manufacturing?
Printers, copiers, fax/multifunction machines
Toner/ink cartridges
Photoreceptors, charge/bias rollers, other printer components
Toners/inks
Chemicals/resins
Print media
Your Technology
Electrophotography
Inkjet
Thermal
Flexo
Other (Specify Below)
Your Application
Production/manufacturing
Research and development
Marketing/competitive benchmarking
Cartridge remanufacturing
Other (Specify Below)
Your Application
Does your company currently use QEA equipment?
Yes
No
What do you want to test?
Print quality
Color quality
Flexo plates
Metal backed plates
ITR sleeves
OPC drums
Charge/bias rollers
Development/magnetic rollers
Transfer rollers
Fuser rollers
Toner fusing
Other
In the response boxes below, please provide as much detail as you can. If yours is a
unique application
or
special requirement
not reflected in the check lists above, please contact us! We specialize in devising the solutions our clients need.
What would an equipment purchase help you achieve?
Additional Comments
What is your role in equipment purchasing decisions?
Evaluate/recommend equipment for purchase.
Approve/make equipment purchase decisions.
Other (Specify Above)
When do you expect a decision to be made?
3 months
6 months
12 months
More than 12 months
Don’t know
How did you hear about QEA?
Trade Show/Conference
Publication
Customer Referral
Internet
Other
How did you hear about QEA?
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Phone
This field is for validation purposes and should be left unchanged.
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