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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.

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If you have already requested an adhesive sample through our website in the past and would like another material, please contact our Applications Engineering Group at 860-482-1010 for further assistance.

Contact Information

General Contact Information
*Prefix:
*First Name:
*Last Name:
*Company:
*Address:

*City:
*State/Province:
*Postal Code:
Country:
*Phone:
Fax:
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Ship to Information Please complete if different than contact information
Prefix:
*First Name:
*Last Name:
*Company:
*Address:

*City:
*State/Province:
*Postal Code:
Country:
*Phone:
Fax:
*Email:

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 material):

*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 fluorescence 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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