Date: *

Company: *

Name: *

Address: *   State / Province: *

Zip Code: *

Telephone: *

E-mail: *

Engineering should contact for additional info: yes no

Application Type (ie Filter, Batteries, LS): old new in development

Potential Quantities: *

Are they using any type of material now: yes no

Does a print exist: yes no

Critical Parameters:

Weight: LWD: SWD:

Insert parameter or ranges

LWO: SWO: Material Type:

List other critical parameters below:

Thickness: %Open: Width:

Is there a sample avialable for evaluation: yes no

End application for material: yes no

Application Description:*