First Name

Last Name

Email

Phone Number

Job Title

Company Name

State/Province AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Outside US/Canada

Pre-Requisite Data For Selection Of Hose A) Media Handled

Description of fluid

B) Operating & Max. Temperature Range: hide

Min Temp (°C)

Max Temp (°C)

Intermittent Temp (°C)

C) Operating & Max Pressure (Kg/cm2)

Vacuum/Under pressure requirement if applicable (Kg/cm2)

D) Application/Location of the hose: Connecting from

Lorem Connecting to

Fitment dimensions and configuration of mating parts

F) Expected movement (flexibility) to be incorporated in the hose design

G) Cuff Length required if applicable (mm)

H) Customer 3D Model of Hose Available? YesNo

Customer 2D Dimensional Drawing available? YesNo

I) Estimated Annual Usage (Units/Year)

J) Special Requirement (if any)

K) Engine Model

Engine HP

Number of Engine Cylinders

Comments

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