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Contact Information

* Name:
Title/Department:
* Company Name:
* Address:
* Phone Number:
* Fax Number:
E-mail Address:

Product Information

Your reference number:

Size	Release Quantity (Pieces)	Estimated Annual Usage (Pieces)
3/8" Nominal
1/2" Nominal
3/4" Nominal
1" Nominal
1 1/4" Nominal

* Packing:
Bulk Packed or Bagged?

Notes:

Crimp rings are blackened unless otherwise specified. Crimp rings are incise marked "HPEX F1807" unless otherwise specified.

Current Supplier

Name:

Current Costs:

We will use the information you provide us on this form to respond to your inquiry and for no other purpose.