EPM FAST QUOTE REQUEST FORM

www.epm.com

To better serve you, please print this form out, fill in the necessary information and fax to (888) 353-7325 or (770) 389-0652. Please fax any drawings or stretches with this form. We will contact you within 1 hour and 59 minutes or less during business hours.
* indicates required field

*Contact Name:

 ___________________________
*Title:

 ___________________________
*Company Name:

 ___________________________
*Address:

 ___________________________
*City:

 ________________ *St/Prov: ______________
*Zip:

 ________________ *Country: ______________
Timezone (in US only): ________________
 
*Date:

 ___________________________
*Phone:

 ___________________________
Ext:

 ________________
Fax:

 ___________________________
*E-mail:

 ___________________________
Website:

 ___________________________

Quantities
*Purchase/Release Qty:

 _______________________ *Annual Qty: _____________________
Specifications
*Material:___________________________

*Type of Seal(s):
Hydraulic Seal
Oil & Grease Seal
O-ring
Back-up Ring
 Mechanical Seal
Pump Packing
Valve Packing
Gasket
 Gasket Material
PTFE Seal
Machined Plastic

Technical Information
S.T.A.M.P.S. (Easy To Remember - 'S'ize, 'T'emperature, 'A'pplication, 'M'edia, 'P'ressure, 'S'peed)
S *Size: (ID, OD, Height):
ID: _________ OD: _________ HT: _________

T *Temperature: (of product being sealed):
_______________ °C °F

A *Application: Type of equipment - pump (rotary, reciprocating), valve, digester, mixer, etc:

*Application Action:
Reciprocating
Rotary		 Static
Combination
*Type of Equipment (pump, valve, mixer, etc.):
___________________________

M *Media: (What material is to be sealed? - solvent, acid, caustic, abrasive?):

 ___________________________
P *Pressure: Stuffing box pressure (actual operating pressure):

 ___________________________
S *Speed in fpm (feet per minute) or rpm (rotations per minute):
________________________
FPM
RPM
*What factors are you trying to achieve?:
High Temperature Resistance
Low Temperature Resistance
Chemical Resistance		 High Pressure (PSI/BAR)
High Speed
Low Speed		 Hydrolisis Resistance
FDA Approved Materials
Other Specifications

Parts Information
(Complete this area for a quote on specific parts)
Qty. Description/Part Number Qty. Description/Part Number
_______

_______

_______

_______		 ___________________________

___________________________

___________________________

___________________________		 _______

_______

_______

_______		 ___________________________

___________________________

___________________________

___________________________

Additional Information
Addtional Information About This Application:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________		 What is the best method to reply to your request?:
E-mail
Fax
Phone

Are you looking for...?:
Better Price
Better Delivery
Better Performance
Are you buying these seals now?:
Yes
No

What is the target price you are trying to achieve?:
$___________________________

 When will you purchase?:

 _______________
When do you need these seals?:

 _______________
How will you pay?:
Credit Card Purchase Order Wire Transfer