Request An Adhesive Sample

Please provide as much information as possible. This will allow us to verify that the product selected is going to provide you with the best solution.

Fields marked with an (*) are required.

If you have already requested a sample through our website in the past and would like another sample,
please contact our Technical Service Group at 860-482-1010 for further assistance.

Contact Information
		Ship to Information: (please complete if different than contact information)
*Contact Prefix:		Contact Prefix:
*Contact Name:		Contact Name:
*Company:		Company:
*Address:		Address:

*City:		City:
*State/Province:		State/Province:
*Postal Code:		Postal Code:
Country:		Country:
*Phone:		Phone:
Fax:		Fax:
*E-mail:		E-mail:

Application Information
How did you hear about DYMAX?
Are you currently working with a DYMAX Sales Partner? Yes No
*If "Yes" who?
*Shipping Carrier:		Account Number**:
**An account number must be provided if you select a Federal Express or UPS service, otherwise the sample will be shipped via First Class Mail.
*End item to be manufactured with DYMAX product (examples: catheter, turbine blade, cell phone, etc.):

*Describe the application (description & purpose of sample):

*Substrates to be bonded or coated (list any coatings and list specific plastics):
Shadowed Areas: Yes No Not Sure

Current Method
Current Product Name:
Current Chemistry:
If "Other" or "None" Please Specify:

Proposed Process
How many parts will you manufacture per hour?		Manufacturing Process: Manual Automated
How do you plan to dispense and cure the proposed material?
Do you have a UV light source? Yes No		*If yes, what kind?

Adhesive Requirements

*Physical Properties (viscosity, hardness/flexibility, color, clarity, or fluorescense needed):

*How do you plan to test the proposed material? (adhesion, thermal, moisture/humidity):

Additional comments or requirements:

Product(s) selected:

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DYMAX Corporation 318 Industrial Lane