Registration form

Works in both Netscape and IE.
ONLY WORKS IF VISITORS HAVE THEIR E-MAIL SET UP ON THEIR BROWSER.

Mr   Mrs   Prof   Dr

First name:

Family name:

Company/Institute:

Street / P.O.Box:

ZIP code:

City:

Country:

Phone:

Fax:

Email:(1)

I inquire as :
End user    Local dealer    Manufacturer (OEM)   

I am interested in the following products
  Densitometer (TLC scanner)
  LabChrom Chromatographic Data Station
  LabChrom Chromatographic Software
  20 bit A/D converter
  OPLC instrument

Intranet password(2)
 Yes please

Comments, special requirements:

(1) In case of intranet password request, anonym addresses are not acceptable (for example hotmail, freemail, yahoo, etc).
(2) For intranet password please fill all the fields correctly.