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(Please, mark 1 of 3 points)*
	Customer	Distributor			Agent

CONTACTS
Name*				Surname*
Company*				Country*
E-mail*				Phone*

PRODUCTION* (Please, mark at least one of the below points)
	Integral skin	Cold-cure			Mono density soles	Direct injection
	RIM	Rigid			Dual density soles	Rubber soles
	Cast elastomer	Semi-rigid			Other
	Rubber				Resin

Description of moulded pieces				Equipment and machine

Number of machines				Type of machine


PU system or type of Rubber in use
Description of PU system or type of rubber*				Equipment and machine


WORKING CONDITIONS
Type of moulds			Spraying systems:*
	Aluminium	Iron			Air gun	Airless
	Resin				Air-assisted Airless	Electrostatic gun
	Others				Others

Moulds temperature°C				Density of foamg/lt.
Time between application and closing of the mould				Application system:
					Manual	Robot

RELEASE AGENT IN USE
Supplier				Code

(Please, mark 1 of 2 points)*				(Please, mark 1 of 3 points)*
	Solvent-based				Concentrate	High solids
	Water-based				Ready-to-use
Type of solvent				Solvent flash point, °C

Consumption, Kgs/month*


Comments and shipping address*


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