Poly
Mod
® 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 Quote
NOTE:
Fields and sections marked by an asterick (
*
) are mandatory.
*
Name:
*
Title
*
Company:
Division
*
Address:
P.O. Box
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City:
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State/Providence
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Postal Code:
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Country
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Phone:
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Fax
E-mail:
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TYPE OF BUSINESS:
Distributor
End User
OEM
Repair Shop
Other
*
INDUSTRY:
Aerospace
Automotive
Defense / Military
Industrial
Medical
*
QUOTE IS FOR:
New Application
Existing Application
New Parts
Existing Parts
Price Comparison
Item
Qty
PTI Part # / Customer Part #
Description
Material
*
SPECIFICATIONS:
*
Material Specifications?
None
Military Specification
D2000 Specification
Other
*
Shelf Life / Age Control requirements:
None
Per ARP5316
Other
*
Customer specific specifcations?
None
Yes
*
PACKAGING:
No specific requirements
Individually Packaged
Bulk Packaged
Other
*
QUALITY REQUIREMENTS:
*
Inspection Level:
AQL 1.0
AQL 2.5
Other
*
Certificate of Conformance required?
Yes
No
*
Additional quality Guidelines?
Yes
No
*
Material Test requirements?
Yes
No
ADDITIONAL INFORMATION
Notes:
Additional Information will be faxed to PolyMod® Technologies Inc. (1-260-432-6051)
Poly
Mod
® Technologies Inc. cannot anticipate or control how these seals are to be utilized, and the circumstances in which they will be utilized. To insure suitability, user testing is recommended. You may
submit an IDS
or contact us for a review of the application.