Applications Questionnaire

Cox Sales Company is an industrial adhesive supplier. In some cases a standard off-the-shelf product or special adhesive is not available due to customer requirements. Therefore, we have to engineer or modify a formulation to meet a specification. This component of our website is designed to help us determine your needs. Please take a few moments to complete the questionnaire below. If you do not have an answer to any of the fields just leave them blank. You may hit the submit button at the bottom of this questionnaire or if you would prefer you may download a PDF copy of this questionnaire and mail or fax it to us at another time.

*First Name:	A value is required.
*Last Name:	A value is required.
*Company:	A value is required.
*Mailing Adddress:	A value is required.
*Shipping Address	A value is required.
*City:	A value is required.
*State:	A value is required.
*Zip Code:	A value is required.
*Country:	A value is required.
*Telphone:	A value is required.
Fax:
*E-mail:	A value is required.
	*Required field
*Note: Is this a residence?	Yes No

APPLICATION SPECIFICS

What is the end product?
Are you looking for an adhesive, coating, sealant, encapsulant or other?

Do you have a written specification? (Example: MMM-A-131 Type 1, class 2)
Has a bond strength been established?
Is a dual component system acceptable?
Substrates to be bonded (Example: natural rubber to Cold roll steel).
	to

UNCURED HANDLING REQUIREMENTS

Desired Viscosity (cps): (Water equals 1 cps)
Does the system need to flow?
Is a non-flowing material desirable?
Desired work Life (minutes):
Desired handling bonds (minutes):
Desired full cure time (minutes or hours):
Gram Mass:
Potting Mass:
Thermal shock cycling:
Performance Parameters:
Major approval criteria:
Approximate dimensions to be bonded:
Cubic inches to be filled:
Does the material have to be conductive?
If Yes, thermally or electrically?
Color part 'A'
Color part 'B'
Desired mix ratio?
Is specific gravity an issue?
Is shock or vibration an issue?
Does the adhesive have to be UV resistant?
Does the adhesive have to be waterproof or water resistant?
Does the adhesive have to resistant to anything?
Are you interested in a waterborne or solvent system?

CURE REQUIREMENTS

Type of cure:
Room Temperature	Yes No
Heat	Yes No
Moisture	Yes No
Reactive	Yes No
Shore Hardness @ 23 degrees C:

SERVICE CONDITIONS

Temperature Range (example: 10 to 120 degrees Centigrade)
Is the temperature constant or intermittent?

Does the product have exposure to:

Solvents:	Yes No
Chemicals:	Yes No
Abrasion:	Yes No
Oils / Fuels:	Yes No
Outdoor Weathering:	Yes No
Other:

PREFERRED METHOD OF APPLICATION

Brush	Yes No
Spray	Yes No
Roll	Yes No
Mix	Yes No
Other:

OTHER REQUIREMENTS OR APPEARANCE CONSIDERATIONS

(Example: Color, Odor, Flammability)

USAGE

Is this application new?	Yes No
Are you presently in production?	Yes No
Estimate of adhesive usage per month:
If you are currently using a product why do you want to change?

SOURCE OF MATERIALS

Application is new and do not have a source:

Yes No

Current supplier:
Product currently being used:
Price currently being paid: