Apex Medical Technologies, Inc.

Prototyping Quote Request Form

This form is to be completed by those customers who have an application for which they believe our dip molding processes would be well suited to meet their needs. Please complete the form to the fullest extent possible, and we will respond directly with a quotation proposal or a telephone call to further discuss the application. Please be assured that the information received will be kept in the strictest confidence. However, if it is necessary to first enter into a Confidentiality Agreement, this would be acceptable as well.

Please Describe Your Application Below

1) Describe the functionality of the part or product:

2) Describe material property/functional requirements:

Or, choose a material from our Materials Page:

If a Polyisoprene or Silicone material is desired, please select below:

Polyisoprene
Silicone

3) Desired Material Properties:

Tensile Strength (psi):
Elongation (%):
100% Modulus (psi):
Tensile Set (%):

4) Part Dimensional Requirements:

Length ("):
Diameter ("):
Thickness ("):

If the part has a profile or is shaped, please describe it or supply a drawing:

5) What prototype sample quantities are needed?

6) Will tooling be supplied? If not, a tooling charge will be included in your quote.

: Yes; No

Name:
Title:
Company:
Address:
City, State, Zip:
Country:
Phone:
Fax:
E-mail: