#str_msg#

Name:#name#
Title
Organization
Address
City
State
Postal Code
EMail:#email#
Telephone
Fax

Is this application:
existing
new

If an existing application, what product/material are you using now?

What is the brand name?

Manufactured by?

Why are you contemplating elimination of this material?

Is there a specification for the material? Yes No

If yes, please complete the information below:

Specification Name:

Issued By:

Available From:

Please check the most appropriate requirement (check all that apply):

Apply	Filter	Sound absorbtion
Coalesce/Diffuse	Meter	Support
Cushion/Pad	Protect	Transmit
Decorate	Reservoir	Wick/Absorb
Demist	Scrub	Wipe
Explosion Suppressant/Baffle	Seal	Other

Please check the most appropriate environment(s) in which the material will be used:

Indoor	Protected	Liquid
Outdoor	Bright Sunlight/UV Light	Other
Exposed	Gas

What is the approx. temperature range the foam will be exposed?

Min: Max: Degrees Celsius or Fahrenheit For Max temperature, is exposure Constant or Intermittent If intermittent, give details:

Additional Info: How is the foam to be used & what is it expected to do? Do you need samples? How else can we help you?