Moliterno, Inc. Fax this form to 978.275.3836
Custom Glass Plates And Cassette (Refer to figure 1) ORDER /QUOTE (CIRCLE ONE)
Notched Glass Plate Measurement
A) Overall width of plate__________
B) Height of notched plate_________
C) Width of ear_________
D) Height of ear_________
E) Thickness of glass plate_________(Use
a micrometer)
Type of Glass _____________________
Rectangular Glass Plate Measurement
F) Width of rectangular plate________
G) Height of plate________
H) Thickness of glass plate_________ (Use a micrometer)
Quantity of Notched plates_________
Quantity of Rectangular plate________
Seamed (sanded) Edges
Yes/No
Additional information or comments:
Information
we need to process your request.
Name_______________________________University/Company_____________________________
E-Mail____________________ Phone__________________________ Fax________________________
How
would you like us to contact you? e-mail, phone, fax
Additional information needed
for your order: 
Purchase Order #__________________________Credit
Card # ___________________________________ Ex. Date:_________
| Billing Information: | Shipping Information: |