Headset Order Form

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Brite Ears LLC Specialized Hearing Systems:
Headset Order Form

Client Information


Client Name
Ship to:
Name
Address
City/State/Zip
Country
Contact
Phone

Product Information

Aviation Headset
(Enter number of items needed)

Telex 5x5 Pro III

	Telex 5x5 Pro III - $240.00/each
	Telex 5x5 Pro III (with portable PTT switch) - $265.00/each

Emergency Headsets
(Enter number of items needed)

EarSet

	Custom Mold - $40.00/each
	EarSet w/Quick Disconnect - $66.00/each
	EarSet w/Quick Disconnect & Noise Cancellation - $86.00/each

T3 (monaural)

	Headset w/Flat Quick Disconnect - $79.00/each
	Headset w/Flat Quick Disconnect & Noise Cancellation - $99.00/each

T4 (binaural)

	Headset w/Flat Quick Disconnect - $105.00/each
	Headset w/Flat Quick Disconnect & Noise Cancellation - $125.00/each

Amplifier Systems for Emergency Headsets
(Enter number of items needed)

General Handset Systems

E-4 Amplifier - $140.00/each

4-Wire Carbon Systems

	EBCX - $118.00/each
	GPCX - $115.00/each

6-Wire Carbon Systems

EBCX-6 - $126.00/each

Accessories
(Enter number of items needed)

	Supervisor Cord - FQDSVM - $45.00/each
	12' Extension Cord - FQDEXT - $45.00/each
	Clothing Clip - HCLIP - $3.00/each
	AC Power Supply - PSUPPLY - $15.00/each
	Headset Adapter for 4-Wire Interface - PJ327 - $12.00/each
	Headset Adapter for 6-Wire Interface (20 inch cord) PJ720 - $40.00/each
	Headset Adapter for 6-Wire Interface (40 inch cord) PJ740 - $80.00/each
	Wind Screen for Microphone - WINSOX - $3.00/each
	Foam Ear Cushion - EARCUSH - $2.50/each
	Cradle for Handset - CRADLE - $15.00/each
	Lighted Crandle for Handset - LCM 01 - $40.00/each
	Headset Helper - HELPER - $8.00/each
	10" Connection Cord - PIGTAIL - $3.00/each
	12' Extension Cord - QDCOIL - $25.00/each

Special Instructions


If you have any special instructions, please explain in the space provided:

Payment Method


Personal Check Company Check Visa MasterCard
Account Name
Account Number		Exp. Date /
		All orders will be sent UPS Ground unless specified above. Foreign countries, please contact us before ordering.


To submit an order, fill out this form, print it, and then either fax it, or mail it to: Brite Ears LLC P.O. Box 6358 Akron, OH 44312 USA Phone: (330) 618-8913 Fax: (330) 784-8884 Click here to go back to the order form list

For more information click Information Request Form and we will be happy to contact you.

Send mail to webmaster@britears.com with questions or comments about this web site.
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All Rights Reserved. Last modified: 09/29/2008