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Accu-Glass Information Request Form
Complete the form and submit via e-mail or download and fax or mail to Accu-Glass, LLC.

Your information will be forward to: Janet
Email: info@accu-glass.com
Office: 1 314.423.0300 Extension: 111 Toll Free: 1 800.325.4796 Extension: 111
Fax: 1 314.423.0413
Street Address: 10765 Trenton Avenue St. Louis, MO 63132 USA

For On-line Quotes, Information and Questions
* Required Field          
*First Name:  
*Last Name:  
*Institution/Organization:  
*Address 1:  
Address 2:  
*City:  
*State:  
*Postal/Zip Code:  
*Country:  
E-mail Address:  
   Phone Number:  
Before submitting personal information to us, we encourage you to read our Privacy Statement and Consent to Use of Data. This Statement contains important information about how we will handle and use your personal information. After you have had a chance to review the Statement, please acknowledge your acceptance of terms by selecting the box below. If you choose not to accept, the information you just completed will not be submitted to Accu-Glass.
* I accept the terms of the Privacy Statement.

*Please send me e-mail updates on news and information related to Accu-Glass products, services and promotions.
          Yes      No


 
Optional Information– To serve you better, please provide as much information as possible:

Application:
* Required Field      
           Infusion Device Exisiting New
           Flush Device Exisiting New
           Capillary Tube Exisiting New
           Electrical / Electronic Components Exisiting New
           Fiber Optic / Photonic Components Exisiting New
           Other Exisiting New
 
Dimensions:        
ID ±      Inches     mm   Microns
OD ±      Inches     mm     
Length  ±      Inches     mm     
      Unique Cross-Section  
     
Quantity:        One-Time   Annual
Target Price:   (ea)
 
Glass Type:
           Borosillicate (Typical Application:infusion / flush / photonics)
           Soda Lime (Typical Application: liquid handling)
           IR Absorbing Sealing Glass (Typical Application: electrical)
           Specialty
 
Flame Polish:   Yes       No               
 
Markings:
 
Additional Information (if available):
Flow rate & how measured:  
Volume (min/nom/max):  
Refractive index:  
Concentricity:  
Roundness:  
End-Cut Quality:  
Coatings:  
Other:  
How did you hear about Accu-Glass?