| Name: | * | Gender: | malefemale | 
| Position: | Tel: | * | |
| Fax: | E-mail: | * | |
| Company: | * | Website: | |
| Address: | |||
| City: | * | Zip: | |
| The adhesive you are currently using: | |
| Please briefly describe the properties that your current adhesive(s) lack: | |
| Substrate: | |
| End-use of the product: | |
| Number of parts needed to be bonded per day: | |
| Bondline size: | |
| Expected curing time: | |
| Application conditions: | Extreme temperatures Outdoors High humidity Contact with chemicals Other conditions | 
| Specify the above “Other conditions”: | |
| Will you consider using two-component adhesive: | YesNo | 
| How to use the adhesive: | |
| The work time you expect (minutes): | |
| When will you need the adhesive: | |
| Do you need dispensing equipment: | YesNo | 
| What service(s) do you need: | SamplesOn-site demonstrationProduct literatureContact information | 
| Additional information: | |
| Code: |  |