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If you prefer to fax us your request, please click here for a printable Adobe PDF version of this questionnaire, and fax your questionnaire to (770) 261-4805.

Your Information

Name

First

Last

Company

Market

Job Function

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Specific Information

P.O.

Requested By

OEM Industry

Return to

P/N

Load/Speed

Qty (U/M)

Part Name

Base Mat’l & Hardness

Annualized Volume

Cure Restriction

Mating Mat’l & hardness

Operating Temp

Current/tested finishes

Motion

Customer Spec

Corrosion Requirement

Testing Criteria

Coating Process Thickness

Liquid Compatibility

Requirement Range

Drawing

Charge

Revision

Your Problem

Please identify the primary problem, e.g. galling, fretting, wear, corrosion, etc

Define what is considered part(s) failure

Visually describe the problem or failure condition of the part(s)

Will blueprints and parts be available for coating selection and submittals?

Attachments

Upload File(s)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Operating problem Revision

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