STAMPED FORM Hose Selection Assistance Company:_____________________________ Phone:______________________________ Contact:______________________________ Email:_______________________________ Address:______________________________ Terms:_______________________________ O.D. I.D. Length Tolerance SIZE in/mm in/mm in/mm in/mm Material Transported External Operating Temperature TEMPERATURE Min. Max. Min. Max. oF/oC oF/oC oF/oC oF/oC APPLICATION Material Transported MATERIAL Internal Operating MEDIA Environment Maximum Pressure Peak Pressure Vacuum PRESSURE PSI/kPa PSI/kPa In. of Hg/kPa Attachment Methods Hole 1 2 Delivery Date: Quantity: Pickup Date: Ship Via: DELIVERY Testing Req’d: Yes / No Type: Certification Req’d: Yes / No Type
STAMPED FORM Hose Selection Assistance Company:_____________________________ Phone:______________________________ Contact:______________________________ Email:_______________________________ Address:______________________________ Terms:_______________________________ SIZE O.D. I.D. Length Tolerance in/mm in/mm in/mm in/mm TEMPERATURE Material Transported External Operating Temperature Min. Max. Min. Max. oF/oC oF/oC oF/oC oF/oC APPLICATION MATERIAL MEDIA Material Transported Internal Operating Environment PRESSURE Maximum Pressure Peak Pressure Vacuum PSI/kPa PSI/kPa In. of Hg/kPa Hole Attachment Methods 1 2 DELIVERY Delivery Date: Quantity: Pickup Date: Ship Via: Testing Req’d: Yes / No Type: Certification Req’d: Yes / No Type