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Name:
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Company:
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City:
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Who is your Kanaflex Rep:
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Contact Phone:
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Email Address:
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What is the hose model #::
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Hose Diameter:
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Hose (Coil) Length:
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Hose Total Footage:
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Purchase Order # (REQUIRED)::
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End User Name:
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End User Address:
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Nature of the claim?:
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Duration of time the hose was in use:
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Application:
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What was the hose connected to:
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Type of material going through the hose:
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Maximum pressure or vacuum pressure:
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Temperature range in this application:
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Hose Lot Number VXXX or CXXX):
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Other Notes:
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