First & Last Name*

Title

Company Name*

Address Line 1*

Address Line 2*

City*

State/Province*

Zip Code*

Phone Number*

Fax Number

E-Mail Address*

Please attempt to complete this application as accurately as possible to ensure proper machine recommendation

General Information

Machine Desired

Type of Material

Application

Material Manufacturer

Phone Number

Fax Number

Material Specs-Individual

"A" Material

"B" Material

Product Name/Number

Viscosity @ 77° F

Ratio, Parts by Volume

Ratio, Parts by Weight

Pot Life/Gel Time

Specific Gravity/lbs. per gal.

Supply Container Size

Filler/Abrasive

Moisture Sensitive

Thixotropic

Agitation Required

Corrosive

Processing Temperature

Viscosity @ Process Temp.

Material Specifications-MIXED

Gel Time

Viscosity

Pot Life

Specific Gravity

Application Requirements

Shot Size

Shot Frequency

Flow Rate

Material Usage

Solvent Used

Description of Application

Machine Options/Requirements (Check all that Apply)

Static Mixer

Dynamic Mixer

Portable/Cart Mounted

Fixed-Mount Dispense Valve

Hand-Held Dispense Valve

Boom Arm

Manual Controlled Shot

Automatic Controlled Shot

Automation/Robot Integration

Material Temp. Conditioning

Re-Circulation

Solvent Flush Purge

PLC Compatible

X, Y, Z Table Integration

Portable/Cart Mounted