| *Denotes a required field |
| Aflex sales engineer |
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| Customer details |
| Company name* |
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| Company contact (Someone at your business we can get in touch with.) |
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| Contact phone |
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| Contact Business email * |
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| Basic information |
| Brief description of application (Give details of all media/chemicals used inside hose.) |
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| Media/Chemicals used inside hose |
| Media/Chemical |
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| CAS numbers (Give CAS numbers of any media/chemicals used inside the hose.) |
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| Concentration |
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| Fluid/gas/other (Please specify if your hoses are used for a fluid, gas or another substance.) |
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| Minimum temperature (Indicate using °C or °F.) |
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| Maximum temperature (Indicate using °C or °F.) |
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| If cyclic, please describe |
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| Minimum pressure/vacuum (Measurements in psi or bar.) |
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| Maximum pressure/vacuum (Measurements in psi or bar.) |
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| If cyclic, please describe |
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| Internal surface of the end fittings (What is the material of the internal surface of the end fittings/pipe/valve etc that the hose is connecting to?) |
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| History |
| Please advise whether this is replacing existing hose assembly(ies) (If NO, please continue to next section) |
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| If YES, please advise type of hose being replaced |
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| Please advise if any problems have occurred with the existing hose(s) |
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| Please describe hose(s) required (Include the bore, length, fittings and any other information) |
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| Antistatic requirements |
| Is antistatic grade hose accepted for this application? (If 'no', please answer the questions below) |
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| Is the media a single phase gas? |
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| Are there any multiphase conditions? (Such as solid particles in fluid, fluid droplets in gas, non-mixable fluid droplets in water etc.) |
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| Is more than one chemical being used - are they put through hose together? |
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| If so, please state groupings (If you answered 'yes' to above, please give details.) |
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| If fluid, what is the maximum flow rate? |
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| If known, what is the electrical conductivity in pS/m? |
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| Chemical conditions |
| Do the chemicals mentioned have any penetrating/diffusing characteristics? If so, please describe |
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| Are any of the chemicals flammable, corrosive, toxic or radioactive etc? If so, please describe |
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| Is there a risk of any of the media/chemicals coming into contact with the outside of the hose or fittings? If so, please describe |
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| Are there any other chemicals in contact with the outside of the hose or fittings? If so, please describe |
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| Are there any other external conditions which could affect the hose? If so, please describe (e.g. sea spray) |
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| Mechanical requirements |
| Is the hose static or dynamic? |
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| If 'dynamic', please describe flexing cycle |
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| Will there be any abrasion of the inside or outside of the hose? If so, please describe |
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| Will the hose be twisted/bent/crushed/pulled excessively in the application? If so, please describe |
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| Flow rates |
| If high flow rates or specified flow rates are required, please state the flow rates required and the pressure drop between the end fittings |
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| Cleaning procedure |
| Please describe fully how the hoses are cleaned (e.g. SIP, CIP, SOP, purging conditions etc) |
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