| Please print this form
and return with your sample. | |||||||||
| Company Name: | ______________________________________________ | ||||||||
| Contact Name: | ______________________________________________ | ||||||||
| Address 1: No PO Boxes! |
______________________________________________ | ||||||||
| Address 2: | ______________________________________________ | ||||||||
| City, State, Zip+4: | ______________________, _____ ______ - _______ | ||||||||
| Country: | ______________________________________________ | ||||||||
| Phone #: | ______________________________________________ | ||||||||
| Fax #: | ______________________________________________ | ||||||||
| EMail Address: | ______________________________________________ | ||||||||
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| Barbed Fitting Information | |||||||||
| Manufacturer: | Material: | ||||||||
| ______________________ | ______________________ | ||||||||
| Catalog #: | Size: | ||||||||
| ______________________ | ______________________ | ||||||||
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| Tubing Information | |||||||||
| Manufacturer: | Material: | ||||||||
| ______________________ | ______________________ | ||||||||
| Catalog #: | Size: | ||||||||
| ______________________ | ______________________ | ||||||||
| Durometer: |
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| ______________________ |
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| Operating Parameters | |||||||||
| Material | Material Type: | ||||||||
| ___ Gas ___ Liquid |
______________________ | ||||||||
| Operating Temperatures | Pressure Requirements | ||||||||
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| Other Requirements | |||||||||
| Custom
Color? ___ YES Pantone#______________ ___ NO |
Custom
Logo ___ YES (please include logo in CAD format) ___ NO | ||||||||
| Special Requirements | |||||||||
| ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ | |||||||||
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| Describe your Application | |||||||||
| Application Description | |||||||||
| ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ | |||||||||
| Problems with sealing? | ___ YES ___ NO | ||||||||
| please
describe: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ | |||||||||
| Retaining Device Currently in Use... | ___ Hose Clamp ___ Cable Tie ___ Ring Clamp ___ OTHER | ||||||||
| please specify type of "OTHER" device... | ______________________________________________ | ||||||||
| This is a new application for our company... | ___ YES ___ NO | ||||||||
| *Total # of
Samples submitting... (1 tube & fitting = 1 sample) |
___ | ||||||||
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| *NOTE: (A minimum of two samples of each are required in order to return an assembled sample) | |||||||||
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| Please contact me as soon as possible regarding this matter. | |||||||||
| I would like an On-Site Demo Offer. | |||||||||
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