Sample Submission and Failure Background Form

The purpose of the form is to get some background information regarding the failure.

Please print, fax or email to us.

Date of failure
ID or Tag No
Sample Description
Sample Function
Service Life in Hours
Material Spec.
Operating Temp.
Operating Pressure
Description of failure
Events leading to failure
Trying to achieve.

        

                                        Part Information

Type of Equipment
Machine - Number
Manufacture
Date of commision
Application of part
Any Repair History
Operating Media

Please provide the following contact information:

Name
Organization
City
State/Province
Zip/Postal code
Country
Work Phone
Fax
E-mail

        Select any of the following options that apply:

Sample submitted by Courier.
Please contact me.
Report require urgently.