Please complete as many fields on this form as possible, to enable us to gather as much information from you as we can.
Name (required)
Address 1
Title
Address 2
Company (required)
City
Contact Number (required)
County / State
Fax
Post / Zip Code
Email (required)
Country
Website
Operating Medium
Fluid Type
Operating Pressure
Operating Temperature
Application - Mounting Class
Speed of Operation (Rod Extend)
Speed of Operation (Rod Retract)
Cycles per min. (1 cycle = extended and retracted stroke)
Operating Environment
Double/Single Acting
Load To Be Moved (PUSH)
Load to be Moved (PULL)
Bore
Rod Diameter
Single/Double Rodded
Rod Thread Male/Female
Style
A&W Dimms
Nett Working Stroke
Grose Stroke
Cushioned None/Front/Rear/Both
Posn Front
Rear
Mounting Style
XI =
Port Size & Thread
Port Posn Front
Air Bleed Yes/No
Port Front
Seals Type Standard/Viton/Other (specify)
Limit Switch (specify type)
Additional Features (specify)
Model Number
Quantity
This document does not constitute a binding contract. A binding contract will not exist until negotiations has been finalised, we receive your formal order in writing and issue you with our acknowledgment form duly signed by an authorised officer of our Company.
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