Custom Design Request

Please fill out this form to submit your Custom Design Request.

(Required Fields Denoted by *)

First Name*	Last Name*	Title*
Department	Company Name*	Street Address*
Internal Mail Stop	City*	State*
Province	Zip/Postal Code*	Country
Phone Number*	Fax Number	Email Address*
Preferred Distributor	Preferred Distributor SalesPerson	New application: Yes     No If existing application, current vendor:
Application Description
Target Price*	Order Qty	Yearly Qty
Prototype Requested	Project Name	Project Due Date
Evaluation Period(days)
Describe Evaluation Process
Requested Bore Size	Stroke	Mount-Vertical Mount-Horizontal Mount-Angle
Mount-Rod Up Mount-Rod Down	Load*	Moment Distance
Load Guided* Yes    No	Torque Required	Spring Force
Single Acting Reverse Acting	Cycle per minute	Velocity in/sec
Duty Cycle	Dwell time between cycles	Pneumatic PSI
Hydraulic PSI	Environment: Outside* Environment: In plant*	Wash down*  Yes    No If yes, state chemical
Temp-High F*	Temp-Low F*
Additional Comments
Select a file to upload (optional) (To send multiple files, please zip them all into one file)