jobst incorporated

HOSE AND TUBING APPLICATION QUESTIONNAIRE

Fill out this form and fax it us: 978-945-6121 or e-mail to sales@jobstinc.com

We will promptly contact you with a solution so make sure and fill in your contact information at the bottom of the page.

HOSE AND HOSE ASSEMBLIES

Application:____________________________________________________________________

ID: _____ OD:_____

Material, Tube: __________________ Material, Cover: _________________ Rein.:___________

Working Pressure: _________________Burst Pressure:_________________________________

Temperature Range: _______________Couplings:_____________________________________

Color.: __________________________ Printing:_______________________________________

Put-up (packaging): ______________________________________________________________

Quantity: ________________________ Releases:______________________________________

TUBING or CUT WASHERS

Application:____________________________________________________________________

_____________________________________________________________________________

ID: _________OD: _______ Wall: _______ Cut or. Length: _____________

Material: ___________________________ Durometer: ____________

Temperature Range.: __________________________ Color:_______________________________________

Put-Up: _________ Quantity: _________ Releases:______________________________________

Other Specs: __________________________________________________________________

Are Prints or Samples available for comparison and quoting purposes? ___________

How did you hear about us?____________________________________________

Your name: _______________________ Title: _____________________________ Company: _______________________ Dep't/Mailing Station: ________________   Address:__________________________________ Telephone: _______________     E-mail: ___________________________________ Fax: ____________________

jobst incorporated po box 8 prior lake mn 55438 952-447-3904 978-945-6121 sales@jobstinc.com www.jobstinc.com