GENERAL INFORMATION
	* NAME		TITLE
	COMPANY
	STREET
	CITY		STATE Choose One AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
	ZIP		* EMAIL
	FAX		* PHONE (DAY)
	* Required Fields
	APPLICATION
	PIPE FLANGE		PUMPS-CENTRIFUGAL/HORIZONTAL SPLIT CASE
	HEAT EXCHANGER		FLUE DUCT
	MANWAY		VALVE BONNET
	COMPRESSOR		OTHER:
	SERVICE CONDITIONS
	MAXIMUM TEMPERATURE (deg. F)
	INTERNAL PRESSURE
	THERMAL CYCLING (per 24 hours)
	OTHER (specify)
	PSIG		CONTINUOUS INTERMITTENT
	VIBRATION		YES NO
	BOLTS		CHEMICAL COMPATIBILITY
	GRADE		MEDIA
	LENGTH		CONCENTRATION
	DIAMETER		pH
	NUMBER		LIQUID GAS OTHER
	FLANGE
	STANDARD		NON-STANDARD
	MATERIAL		MATERIAL
	SIZE		I.D./O.D.
	RATING		FLANGE THICKNESS
	SURFACE FINISH		BOLT CIRCLE DIAMETER
	CONCENTRIC PHONOGRAPHIC		SURFACE FINISH
	FACE (raised, flat, tongue, etc.)		CONCENTRIC PHONOGRAPHIC
			FACE (raised, flat, tongue, etc.)
	COMMENTS

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SUTTON-CLARK Gaskets and Sealing | 1705 Brook Road | P.O. Box 26367 | Richmond, Virginia 23220 | Phone: 804-643-8311 | Toll Free: 1-800-848-8311
SUTTON-CLARK Gaskets and Sealing | Norfolk Branch | 1417-G Kelland Drive | Chesapeake, Virginia 23320 | Phone: 757-545-8300 | sales@gaskethouse.com