NOTE: Fields and sections marked by an asterick (*) are mandatory.

*Name:

*Title

*Company:

  Division

*Address:

*State/Province

*City:

*Country

*Postal Code:

Fax

*Phone:

 *E-mail:

*TYPE OF BUSINESS:

SELECT TYPE OF BUSINESS Distributor End User OEM Repair Shop Other

*INDUSTRY:

SELECT INDUSTRY Aerospace Automotive Defense / Military Industrial Medical

*QUOTE IS FOR:

SELECT QUOTE New Application Existing Application New Parts Existing Parts Price Comparison

Item

Qty

PTI Part # / Customer Part #

Description

Material

*SPECIFICATIONS:

*Material Specification:

Material Specification None Specific Specification

Additional Quality Requirements:

Additional Quality Requirements None Yes

*Shelf Life / Age Control Requirements:

Shelf Life / Age Control requirements None Per ARP5316 Other

*Customer Specific Specifications?

Customer specific None Yes

*PACKAGING:

SELECT TYPE OF PACKAGING No specific requirements Individually Packaged Bulk Packaged Customer Specific Requirements

*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.

PolyMod 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.