Custom Peripheral or Device Request Form

Instructions: Please fill out this form to the best of your ability. If you would like to speak with us directly, feel free to contact us at – 1-800-333-6335 .

Device Type	We would like A.C.C. Systems to design/build: (Indicate one) Choose an item.
If you would like us to design/build an accessory or peripheral…	Who is the manufacturer of your device or computer? Click here to enter text.
What is the model of your device or computer? Click here to enter text.
What is the problem with the current design or what would you like it to do? Feel free to elaborate in detail if needed. Click here to enter text.
If you have additional comments or suggestions as to how we can provide a favorable design, please let us know.	Click here to enter text.
What is the minimum quantity of items needed?	Click here to enter text.
Please provide your contact information.	Name: Click here to enter text. Company / Municipality / Govt. Branch (if any): Click here to enter text. Address: Click here to enter text. Phone Number: Click here to enter text. Email Address: Click here to enter text.

Upon completion of this form, please either email it to cds@accsystemsinc.com or fax it to: 1-631-750-9241.

Please allow at least two business days for our engineers to gather preliminary design thoughts. We will contact you with our response regarding design challenges, engineering procedures, prototype availability, and production needs (if applicable).

Thank you!