Size of hose ID?

Length of hose in inches?

Type of fittings and alloys to be used ?

First Fitting Type	First Fitting Alloy
Second Fitting Type	Second Fitting Alloy

Is it
suction   pressure

Media to be conveyed?

What is the normal working pressure?

What is the maximum working pressure?

What is the normal working temperature?

What is the coldest working temperature?

What is the hottest working temperature?

Are there any unusual bending requirements?

What is cover of hose exposed to?
Oil or Grease
Acids
Ozone
Severe Abrasion
Abuse
Weathering
Other    If other, please explain.

Is static a problem? yes no       If yes, please explain.

What hose is in use now?

How long has it been in service?

If it has failed, how did it fail?

Were there any early signs of failure?
yes  no

Additional Comments

Name of individual inquiring.

Company Name.

Address

City

State       ZIP

Phone Number

Email address