ONLINE ORDERING FORM

Customer

First Name *

Last Name *

Phone Number *

Email Address *

PO

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Size *Inside diameter, length, OD if applicable.

Temperature *Internal, external, min & max

Application *What is the hose to be used for? Water? Dry Air? Chemical? Oil?

Material *What type of product will be conveyed?

Pressure *What is the normal working & burst pressure?

Ends *What type, size, & thread couplings?

DeliveryWhen and where will it be needed? Special packaging required?

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