Bill to Name
*
Contact Name
*
Billing Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Day Time Phone
*
Other Phone
Email
*
Safariland/TCI Customer ID - Account Number
Reference Number (example PO# or Order#)
Payment Method
Product is under warranty
Pay upfront with credit card
Bill agency or department
Original Order Number
*
Ship to - Company/Attn
Is the address same as above?
Yes
No
Shipping Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Shipping Email
*
Shipping Phone
*
Product Information
Product Model Number
Radio Model Number
Type of Microphone Used
Number located on back of mic, opposite side of talk sleeve
Style of Headset Used
Type of PTT
Is This A Radio Interface/PTT Retrofit*
*
Yes
No
What Radio Do You Currently Use With It?
What Radio Do You Want to have it Work With?
Is this an ARC Mount Retrofit*
*
Yes
No
Please note if you have a behind the head suspension this will be a permanent modification and a helmet will be required at all times.
Which one do you need?
Mount Adapter
ARC Mount Adapter
Helmet Model
Helmet Style
Rail Manufacturer Model
Detailed description of the problem and any special instructions
*