Moliterno, Inc. Fax this form to 978-433-7971
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 : Sec. Code :
Billing Information: Shipping Information: