Request Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0><TABLE cellSpacing=0 cellPadding=0 border=0> <TBODY> <TR> <TD vAlign=top background=050285a1erlcgo.gif bgColor=#006699 colSpan=2 height=90 TEXT="#080000" bgproperties="fixed"> <DIV><FONT face=Arial color=#ffcc66 size=5><B>Bearing Engineering Company</B></FONT><B>     |     </B><A title="Bearing Engineering Company" href="index.htm" target=_top><U><B>Home</B></U></A></DIV> <DIV><A title="About Us" href="id2.htm" target=_top><U>About Us</U></A>   |   <A title="Products Services" href="id5.htm" target=_top><U>Products & Services</U></A>   |   <A title="Contact Us" href="id7.htm" target=_top><U>Contact Us</U></A>   |   <B>Request Form</B></DIV> <DIV></DIV></TD></TR> <TR> <TD vAlign=top width=185 background=026d4c00dkelyh.gif bgColor=#ffcc66 TEXT="#080000"> <DIV><IMG height=81 hspace=0 src="05fb4510.gif" width=180 align=bottom border=0></DIV></TD> <TD vAlign=top bgColor=#ffffff height=390 TEXT="#080000"> <DIV><I>Request Form</I></DIV> <DIV> <FORM action=http://formmail.trellix.com/servlets/TlxMailer method=post><INPUT type=hidden value=FirstName,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,Comments name=tlx_SortOrder><INPUT type=hidden value=2 name=tlx_FormIndex><INPUT type=hidden value="Thank you for your request for information." name=tlx_OKMessage><INPUT type=hidden value=1 name=tlx_SendMode><INPUT type=hidden value="A request form was submitted" name=tlx_Subject><INPUT type=hidden value=becocorp@bearingengineering.com name=tlx_EmailTo> <TABLE cellSpacing=1 cellPadding=0 align=center border=0> <TBODY> <TR> <TD align=left>First Name:<BR><INPUT maxLength=100 size=30 name=FirstName></TD></TR> <TR> <TD align=left>Last Name:<BR><INPUT maxLength=100 size=30 name=LastName></TD></TR> <TR> <TD align=left>Email:<BR><INPUT maxLength=100 size=30 name=Email></TD></TR> <TR> <TD align=left>Company:<BR><INPUT maxLength=100 size=30 name=Company></TD></TR> <TR> <TD align=left>Address Line 1:<BR><INPUT maxLength=100 size=30 name=Address1></TD></TR> <TR> <TD align=left>Address Line 2:<BR><INPUT maxLength=100 size=30 name=Address2></TD></TR> <TR> <TD align=left>City:<BR><INPUT maxLength=100 size=30 name=City></TD></TR> <TR> <TD align=left>State:<BR><INPUT maxLength=100 size=30 name=State></TD></TR> <TR> <TD align=left>Zip:<BR><INPUT maxLength=10 size=10 name=Zip></TD></TR> <TR> <TD align=left>Phone Number:<BR><INPUT maxLength=14 size=14 name=Phone></TD></TR> <TR> <TD align=left>Comments:<BR><TEXTAREA name=Comments rows=5 cols=30></TEXTAREA></TD></TR> <TR> <TD align=right><INPUT type=reset value=Reset> <INPUT type=submit value=Send name=tlx_send></TD></TR></TBODY></TABLE></FORM> </DIV></TD></TR></TBODY></TABLE></body>