SAMPLE REQUEST FORM

 SRF20240427-1
 Section I. Contact Information
Contact:
Company:
Address:
Address:
City, State Zip,
Country (non-US):
Phone/Fax:
Email:
Date:
Tech Rep:
 Section II. Application Information
 Activity Information - Why is This Sample Being Sent? (Required for All Samples)
 1. Comments:
 Application Information (White Sections Below are Required for New Application)
 2. Referral:  3. Industry:
 4. End Item  5. Substrates 1:
 6. Parts/Yr:  7. Substrates 2:
 8. Liters/Yr:  9. Substrates 3:
10. Application: Bonding Tracking Coating Sealing Potting Masking Equipment Other:
 Current Method (Adhesive,Curing,Dispensing)
11. Does Customer Have A Light Source? (If so, What Type?): 12. Shadowed Areas? Yes No Not Sure
13. Comments:
 How Will Parts Be Tested? (Type of Test, Minimum Requirements)
14:
 Adhesive Requirements (Viscosity, Hardness/Flexibility, Color, Clarity, Fluorescence, Thermal Requirements, Specifications,etc)
15.