Custom Bag Questionnaire

Your Name

Title

Company Name

E-mail Address

Web Site

Mailing Address

City     State/Province

Postal Code     Country

Phone
   Ext.

Fax

BAG SIZE & DESCRIPTION:

ANTICIPATED PRODUCT USE:

Blood handling
Drainage
Fluid administration
Waste
Long-term storage
Other:

POTENTIAL QUANTITIES:

First order
Per month
Per year

PACKAGING REQUIREMENTS:

Bulk-pack Individual
Other:

MATERIAL DESCRIPTION:

Thickness: mil
Class Vl medical grade: yes no
Vendor name:
Vendor material number:

Type of material:
PVC EVA Polyurethane
Other:

PORTING SPECIFICATIONS:

Total number of ports required:

Port:   OD   ID   Length   Placement  

Port:   OD   ID   Length   Placement  

Port:   OD   ID   Length   Placement  

Other port data:

Vent required: yes no   Placement:

Other features required:

Date quotation required: