Replacement Cleaner Blade Identifier & Quote Form

You may:

• Complete this form online
  Print the resulting information
  Fax printout to (440) 255-7460
  - OR -
• Print out the PDF version of this form
  Fill in by hand
  Fax form to (440) 255-7460

Call for Technical Support 800-380-3555

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Requested by (required):		Date:
Company (required):
Phone (required):		Fax:
E-mail (required):
Basic Belt Cleaner Information: Please complete as much as you can.
Belt Width:		Manufacturer:	Martin Engineering Gordon/Arch ASGCO Argonics Flexco Other
		If Other, Manufacturer Name:
Part Number:		Trade or Model Name:
If you don’t know the Manufacturer & Part Number, please complete as much as you can in the highlighted area, our technical staff will research and contact you.
Additional Blade Information
Blade Type:	One Piece Multiple Pieces	Blade Color?
Blade Width?		Blade Height?
How does the blade attach to the cleaner frame?		Track Pin and Slot "Pound On" Other
		If Other, how?
Position of Cleaner in relationship to head pulley?		Primary Cleaner (@ approximately 3 o'clock) Secondary Cleaner (@ approximately 6 o'clock)
Do you want an optional proposal for a "non OEM" Blade?		YesNo
Optional: If you would like us to contact the customer directly or set up a conference call between you, the customer and our specialist for technical support please supply the customer’s contact name and phone number.
Customer Name:		(Title):
Customer Phone:		Customer Fax:
Comments:

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