Before sending in your samples  please read the Guidelines   by clicking here

Customer Test Request Form
PERSON COMPLETING FORM
       
       
       
       

HOW WOULD YOU LIKE TO RECEIVE THE RESULTS?
       
       
       

MAILING ADDRESS
       
       
       
       
              
       

FAX NUMBER
       

EMAIL ADDRESS
       

END-USER INFORMATION
       
       
       
       
              
       

DISTRIBUTOR INFORMATION
       
       
       
       
              
       

DATE OF REQUEST
       

CUSTOMER DEADLINE
       

       

PRIORITIZATION
       POTENTIAL:
       NECESSITY:
       EXISTING:
       IMPACT:

PRIORITIZATION
       POTENTIAL:
       NECESSITY:
       EXISTING:
       IMPACT:

DESCRIBE THE GOAL OF THE TEST, CUSTOMER APPLICATION, AND USAGE
       

DOES THE CUSTOMER REQUIRE A SPECIFIC TEST METHOD(S) BE USED
       
       

       



ID MFR BRAND MSDS PDS DILUTION (%) pH TEMP (C/F) METHOD PROTECTION COMPATIBILITY W/ SPECIFICATION ADD ANOTHER?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
 



PART ID TYPE OF METAL/LOCATION CORE WAS TAKEN COATED WITH/LENGTH OF TIME COATED OPERATION QUANTITY (# OF PARTS) RETURN REQUESTED ADD ANOTHER?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

          *If no return is requested, parts will be discarded after 21 days.






Version 1, issued 06/12/2010. Supersedes: none.