| Information Request Form |
All required fields indicated by * must be completed/selected before the form may be submitted |
| First name* |
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Last name* |
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| Company name* |
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| Company address* |
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| City* |
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State/Province |
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| Zip/Postal Code* |
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| Country* |
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| Tel. |
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Fax |
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| Corporate E-mail* |
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How did you hear about EXCLUCENT™?
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What application would you like to use EXCLUCENT™ for (if more than one application please rank in order of importance)?*
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Do you intend to use EXCLUCENT™ in an existing product or in a future one?*
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Would you like to have EXCLUCENT™ provided as a roll or as rectangular sheets?*
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Do you have special requests: (e.g. self adhesive film, planarization, customization of pitch, resistance or mesh thickness, interliner)?
If yes, please describe:
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When do you need to have the EXCLUCENT™ shipped to you?*
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What is your preferred shipping arrangement (e.g. UPS; USPS)?*
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Shipping details (if different from contact information provided in section 1): |
| Name |
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| Company name |
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| Company address |
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| City |
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State (Province) |
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| Zip Code |
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| Country |
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Assuming that EXCLUCENT ™ provides the desired solution for your application, what quantity of EXCLUCENT ™ material do you expect to order on a yearly basis, in the next five years?*
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