Questionnaire Form

General Information

Company	Contact	Phone
Address	Email	Drawing Provided? Yes No

Application Conditions

Media to Be Sealed	Liquid Gas Combination
Pressure (psi): max/min	Temperature (°F): max/min
Media Properties, if known: pH	Concentration

Flange Information

Material of Construction
Type:  Welding Neck Lap Joint  Other
ASME Flange Class	Diameter(s)
Facing:  Raised Face Full Faced Blind  Other
Custom Flange:  Non Standard Round Rectangular Oblong  Other
Non-Standard Dimensions: ID/OD	Side Length	Side Width

Bolting Information

Material and Grade	Diameter	No. of Bolts	Bolt Circle
Condition:   Lubricated Dry PTFE or Xylan coated Galvanized  Other

Tongue and Groove

Groove ID/OD:

Groove Depth

Tongue Height

Assistance

For any questions, please call (800) 463-7839, or fax (888) 463-7839

Comments / Current Problems / Questions