Internal Client Data Entry This form is private and only visible to admins and editors. Notification emails are not sent. "*" indicates required fields Contact InformationName* First Last Date of BirthMust be 16 years and older Year Month Day Email* Phone*Shipping InformationShipping Address* Street Address Address Line 2 City Province British ColumbiaAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code OrderPlease Select Your Product*IEM Ear ImpressionsDrifters - Sleep EarplugsConcertos - Musician EarplugsProtectors - Industrial EarplugsRangers - Shooting EarplugsRiders - Motorcycle EarplugsAqua Block - Swim EarplugsAqua Block Pro - Swim EarplugsEarphone TipsRadio Comm. EarpieceVCRM-1 Race MonitorsVCEP-1 Custom EarphonesVCEP-2XB Custom EarphonesVCEP-3 PRO Custom EarphonesVCEM-1 Custom IEMVCEM-2XB Custom IEMVCEM-3 PRO Custom IEMsingle of pair Single ear only (not a pair) Which Ear?* Right Ear Left Ear Material for IEMs Silicone Acrylic Add Detachable Neck Cord? Yes, I want a detachable neck cord Solid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter DR 5 Filter DR 10 Filter DR 15 Filter DR 20 Filter Our motorcycle earplugs do not come with a permanent neck cord option due to their shallow profile. (r)Neck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord paNeck Cord?* None Permanent Neck Cord Detachable Neck Cord Convertible Neck Cord rgaAcoustic Filter Strength* ER 9 Music Filter ER 15 Music Filter ER 25 Music Filter DM 10 Music Filter (mini) DM 15 Music Filter (mini) DM 25 Music Filter (mini) DR 10 Filter (mini) DR 20 Filter (mini) cSolid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter DIM 9 Impulse Filter DIM 12 Impulse Filter DIM 19 Impulse Filter rgSolid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter DR 10 Filter DR 20 Filter DI 25 Industrial Filter DIM 9 Impulse Filter DIM 12 Impulse Filter Solid (Class A) - Maximum noise reduction. Filtered - suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard. Higher numbers block more sound. (pa)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter Solid (Class A) - Maximum noise reduction. Filtered - suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard. Higher numbers block more sound. (pa1)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter Solid (Class A) - Maximum noise reduction. Filtered - suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard. Higher numbers block more sound. (rga1)Solid or Filtered?* Solid (No filter) Hocks Noise Braker® Filter Solid (Class A) - Maximum noise reduction. Filtered - suppresses noise to a safe hearing level, while allowing important, normal conversation to be heard. Higher numbers block more sound. (pa1)filter data See filter data Cable Options* 20" Short Permanent Braided 58" Long Permanent Braided 50" Permanent w/In-Line Mic Style* Full-Shell Full-Shell Low Profile Half-Shell Half-Shell Low Profile Canal Style* Full-Shell Full-Shell Low Profile Half-Shell Half-Shell Low Profile Canal Skeleton rc*Please note that Triple Driver Earphones come in clear silicone only due to the placement of the drivers during manufacturing. A layer of colour can be added on the faceplate portion only for an additional fee, if requested. Solid Colour or Swirl?* Solid Colour Make with 2-Colour Swirl Colour* Same colour for both Different colours for left & right Choose Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose LEFT Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose RIGHT Colour* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose Swirl Colour 1* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dChoose Swirl Colour 2* Black Purple Teal Pink Red Blue Lime Green Sea Green Orange Yellow Beige Clearish dOption ✨ Add Glitter âš¡ Add Glow in the Dark Choose Colour* Black Red Blue Clear cChoose LEFT Colour Black Red Blue Clear cChoose RIGHT Colour Black Red Blue Clear cChoose Colour* Black Red Blue Clear Light Orange Light Lime pChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime pChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime pChoose Colour* Black Red Blue Clear Light Orange Light Lime rgChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime rgChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime rgChoose Colour* Black Red Blue Clear Light Orange Light Lime rdChoose LEFT Colour* Black Red Blue Clear Light Orange Light Lime rdChoose RIGHT Colour* Black Red Blue Clear Light Orange Light Lime rdChoose Colour* Red Blue Light Orange Light Lime abChoose LEFT Colour* Red Blue Light Orange Light Lime abChoose RIGHT Colour* Red Blue Light Orange Light Lime abChoose Colour* Red Blue Light Orange Light Lime abproChoose LEFT Colour* Red Blue Light Orange Light Lime abproChoose RIGHT Colour* Red Blue Light Orange Light Lime abproChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcetChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White rcChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcrmChoose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep1Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep2Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcep3Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem1Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem2Choose Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem3Choose LEFT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem3Choose RIGHT Colour* Black Brown Beige Purple Hot Pink Red Blue Orange Lilac Green Lime Turquoise Yellow Grey Clear White vcem37-Day RUSH Add 7-Day RUSH (Earplugs) Add 7-Day RUSH (earphones) 7-Day Rush is manufacturing time only (business days). Does not include shipping time. However, we try our best to deliver RUSH orders within 7 days.Any Special Requests?Product Name Δ
