Embedded Content - Inside Safariland

Bill to Name*

Contact Name*

Billing Address*

Street Address City State ZIP Code

Day Time Phone*

Other Phone

Email*

Safariland/TCI Customer ID - Account Number

Reference Number (example PO# or Order#)

Payment Method

Original Order Number*

Ship to - Company/Attn

Is the address same as above?

Shipping Address*

Street Address City 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**

What Radio Do You Currently Use With It?

What Radio Do You Want to have it Work With?

Is this an ARC Mount Retrofit**

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?

Helmet Model

Helmet Style

Rail Manufacturer Model

Detailed description of the problem and any special instructions*