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Contact Information

Name

E-mail

Phone

Fax

Company Name

Business Type

Country

Address 1

Address 2

City

State

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Zip

Functional Requirements

Working Pressure

psi

Vacuum

in Hg

Temperature (max)

deg F

Temperature (min)

deg F

Fluid

Angular Movement

degrees

Lateral Movement

degrees

Material to Transfer

Material Requirements
(leave blank if not sure)

Hose

End Fitting

Fit Requirements

Pipe Diameter

inches

Length Requirement

inches

feet

End Connection (Side 1)

End Connection (Side 2)

Other Requirements or Pertinent Information
(flexibility, weight, external conditions, conductivity, etc.)