CUSTOMER INFORMATION
*Company Name:
*Address:
*City:		*State:	*Zip:
Country:
*Contact Name:
Title:
*Phone No.:		Fax No.:
*Email Address:

INJECTION MOLDING MACHINE
Manufacturer:
Tonnage:
SPI Interface:	Choose one... Yes No
If NO SPI - Serial No.:			Manufacture Date:

PART / MOLD INFORMATION
Name / Number:
Parts Release Side:	Choose one... Operator Back
Cycle Time:	(mold close to mold close) seconds - Choose one... with Operator without Operator
Number of Cavities:			Runner System: Choose one... Hot Runner Sub-gated Side Gated Center Gated 3-Plate
Remove:	Choose one... Parts only Runners only Parts and Runners	Parts/Runner retained on mold: Choose one... Moving Fixed
Type of Ejectors:	Choose one... Hydraulic Mechanical

FOR PARTS REMOVAL APPLICATIONS ONLY
Can parts be ejected so they can be removed with negligible force, but do not fall: Choose one... Yes No
If NO, please explain:
Do parts pull straight off of the mold, in line with clamp travel, without twisting or turning: Choose one... Yes No
If NO, please explain:
Are there special part gripping or handling requirements: Choose one... Yes No
If YES, please explain:
Is gate cutting required:	Choose one... Yes No	If YES, maximum allowable vestage: inches
Additional Comments: