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Consultation Request Form ( )

Complete the form below to Schedule a FREE Consultation. Providing as much information as possible will allow us to verify that the product selected is going to provide you with the best solution. A DYMAX Representative will contact you upon completion of the form.

Fields marked with an (*) are required.

Contact Information

*Salutation:
*First Name:
*Last Name:
*Title:
*Company:
*Address:

*City:
*State/Province:
*Postal Code:
*Country:
*Phone:
Fax:
*Email:
Best day/time to be contacted:

Application Information
*How did you hear about DYMAX?

Are you currently working with a DYMAX Sales Partner?
*If "Yes" who?

*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:

Current Method
Current Product Name:

Proposed Process
How many parts will you manufacture per hour?
Manufacturing Process:
How do you plan to dispense and cure the proposed material?
Do you have a UV light source?
*If yes, what kind?

Additional comments or requirements:

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