Date:

Customer Name:

Current customer New customer

Company:

Address:

Telephone:

Fax:

Email Address:

Potential:
High     Medium     Low

Comments:

Level of interest:
Plastube:     High     Medium     Low

Polyfoil:       High     Medium     Low

Monolayer:  High     Medium     Low

Coex:          High     Medium     Low

Other:         High     Medium     Low

Other:

Currently using tubes:
Yes     No    

If yes, from:
Supplier name:

If no, are they buying components?:
Yes     No    

Description:

Customer Request:
Samples     Brochure     Other    

Description of request:

Currently working on project:
Yes     No