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
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
