Diversified Electronics

Please use the form below to receive a quote on any of our rental equipment:

Are You A Current Customer of Ours?

Yes

Rental Start Date

Rental End Date
(If known at this time)

Delivery Method

Required Frequency

Coverage Required

Describe Your Operations Environment?
(Choose all that apply)

	Open Area
	Light Forest
	Heavy Forest
	Large Hills
	Lightly Populated/Rural
	Residential
	Medium City/Urban Area
	Industrial Coverage
Please list special Circumstances Below:

Have You Ever Used a Two-Way Radio?

Yes

If yes, What type?

Select equipment (Choose all that apply)

Below, list any other equipment you might need.

Your Contact Information

*Contact Name:

*Address:

*City:

*State:

*Zip/Postal Code:

*Country:

*Phone Number:

*Email Address:

*Company:

What is the best way for us to contact you?

Phone

E-mail

Mail

Receive email updates from Diversified Electronics:

Yes