Application Description
Company:

Contact: 

Title:   

Address1:

Address2:

City:                St:  Zip:
  
Phone:               Extension
 
Fax:     

Email:

How did you hear about HERNON ?

Can samples of the substrates be sent to Hernon?
  Yes  No
Substrates to be bonded:
 to 
Size of bonding area: 
Is complete coverage required? Yes  No
Substrate Diametrical Clearance/Gap: 
What must bonded assembly resist? - Check all that apply
 Low Temperature	 High Temperature
 Water			 Oil
 Vibration/Impact
 Chemicals - describe:
Other Considerations: 
Projected Estimated Usage - 	
Annually:Monthly:
What brand are you currently using or sampling?

Please list good features:
Please list bad features: 
What determines a good bond?
Would you like information on application equipment?
   Yes  No
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You can expect a response in 24 - 48 hours.