Name: Job Title:

School: Phone Number:

e-mail: Shipping Address:

City: State:  

Zip/Postal Code:

Course Name/Topic Being Covered:

Date Samples Are Needed By:

Number of Students Enrolled in the Course:

Are you interested in an in-class product presentation where an igus representative visits the classroom? Yes    No

If yes, please tell us what dates:
What product line(s) are you interested in?
Check all that apply: Cable Carrier  Bearings  Cable  Linear Guide Systems

Tell us about your curriculum plans:

Will igus products be used as demonstration tools or as components in student projects? Explain:

Do you need catalogs? Yes No
If yes, which catalogs would you like to receive?:
E-Chain/Cables Bearings/Linear guides
Catalogs on CD

What products/parts do you need? Be sure to list quantity and/or length of each and list part numbers if you know them:

If you don't already know what products you need, please list all relevant technical information and questions here:

How did you hear about the Y.E.S. Program?
Direct Mail
Internet Search
Robotics website (Please Specify)
Colleague
Other (Please Specify)

Other questions/comments:

If you have any colleagues interested in receiving information about the Y.E.S. Program, please list their name, email and/or shipping address and phone number below and igus will contact them: