Jacobs and Thompson

Please fill out all of the fields below, and one of our sales representatives will get back to you as quickly as possible.

Customer:

	Customer Contact Information

Phone:

Address:

Fax:

Email:

	Part Information

Part Number:

Estimated Annual Volume:

OEM: (if applicable)

Model Year: (if applicable)

Model: (if applicable)

	Part Dimensions

Width:

Length:

Thickness:

Adhesive required?	Yes No

	If Yes...

OEM Specification:

Substrate:

Part Orientation:	Flat Simple Contour Wrap Around

Mechanically retained?	Yes No

	If Yes....

Performance Temperature:	Less than 125�F 125�F - 165�F More than 165�F

Additional Information:

Questions, Comments or Suggestions?