Spare Parts WorksheetIf you prefer to print and fax this form, click here for PDF. Please enable JavaScript in your browser to complete this form.Company Name *Contact Name *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Please provide the following information so we can determine the extrusion tooling that best suits your needs. Email a product drawing if available.Extruder MakeExtruder Model / SizeType of Polymer or Elastomer Extruded:Type of Flange:Clamp-onBolt-onLargest Core OD or Tube ID:Largest Finished OD:Type:Adjustable Center CrossheadFixed Center CrossheadIn-Line DieOther (Please Specify Below)OtherQuantity:Application:PressureJacketing / SleevingTube ExtrusionStriping (Number of Stripes)Encapsulated? (Yes or No)Other (Please Specify Below)Number of StripesEncapsulated: Yes or NoOtherMaterial:420 Stainless Steel C-276 Hastelloy OtherFittings Required:Air FittingVacuum FittingSpecify quantities requested and any special instructions:Submit
