Customer Name:

Address:
City:
State:
Zip:

Contact Phone#:

Description of application (Include type of equipment plus description of Fluid system.)

Hose & Size (if known)
Overall Length
If size is unknown, specify fluid and flow rate
Fitting requirements (size, material, type)
One End
Other End
Fluid being conveyed
Fluid temperature ° F Max.
° F Min.
° F Normal
Temperature of surrounding atmosphere ° F Max.
° F Min.
Fluid Pressure PSI
Vacuum ( inches Hg)
Pressure Cycle PSI Max.
PSI Min.
Frequency
Surges (please explain)
Static Bend Radius
Flexing Application Bend Radius
If flexing is involved, please specify the following:
Frequency:
Amplitude of Motion
Additional special requirements

Sleeve or guard required
Other factors involved
Number of units required