PolyMod® Technologies Inc. P.O. Box 10180 Fort Wayne, IN 46851-0180 USA Phone: (260) 436-1322 Fax: (260) 432-6051 Email: PolyModCZ@comcast.net Request for Information   NOTE: Fields and sections marked by an asterick (*) are mandatory. *Name: *Title *Company:   Division *Address:   P.O. Box *City: *State/Providence *Postal Code: *Country *Phone: *Fax   E-mail:     *TYPE OF BUSINESS: Distributor End User OEM Repair Shop   Other *INDUSTRY: Aerospace Automotive Defense / Military Industrial Medical   I AM INTERESTED IN: Have a PolyMod® Technologies Inc. representative contact me re: PolyMod® Advantage UltraMod™ Elastomer Materials, specifically PolyFluor™ Materials, specifically Aerospace Seals, specifically Industrial Seals, specifically Technical assistance regarding a specific application or sealing issue       (Please fill out an Engineering Spec form..)   MORE INFORMATION: Please describe any additional information you require: You may also contact PolyMod® Technologies Inc. by Telephone: 260-436-1322 Facsimile: 260-432-6051 Email: PolyModCZ@comcast.net Mail: P.O. Box 10190 Fort Wayne, IN 46851-0180 U.S.A