First Name
Last Name
Company Name
Address
City
State —Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
Zipcode
Company Type DistributorWholesalerManufacturerConsumerOther
If you chose "Other" as Company Type, please explain
Email (required)
Phone Number (required)
Fax Number
Brush Quantities Needed
Brush Application
A. Length of Brush Face (inches)
B. Overall Length of Shaft (inches)
C. Shaft Extension -Left- (inches)
D. Shaft Extension -Right- (inches)
E. Shaft Diameter -Left- (inches)
F. Shaft Diameter -Right- (inches)
G. Brush Diameter (inches)
H. Shaft Material —Please choose an option—AluminumStainless SteelSteelOther
– If "Other" is selected, please indicate type
I. Keyway
– Length (inches)
– Width (inches)
– Depth (inches)
J. Brush Channel Size —Please choose an option—#7 W=.320 (inches) H=.340 (inches)#4 W=.194 (inches) H=.196 (inches)#3 W=.143 (inches) H=.158 (inches)
K. Filament Type —Please choose an option—NylonPolypropylenePolyesterTampicoHorse HairBrassPhosphorous BronzeStainless SteelCarbon SteelOther
L. Lead
M. Left or Right Hand Wound
Additional Information
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