COMPANY NAME: 
YOUR NAME: 
STREET ADDRESS: P.O.BOX NUMBER: 
CITY: STATE: ZIP CODE: 
PHONE NUMBER: FAX NUMBER: 
EMAIL ADDRESS: 

THE ABOVE INFORMATION IS REQUIRED FOR REPLY

REASON FOR INQUIRY?    General floor repair        Planning to Resurface     Planning to coat or seal 

How would you like us to reply to your inquiry?    Telephone      fax      mail      email 

Type of floor?     Concrete      Wood      Wood Block      Asphalt 

     Other (explain):                  .

If wood, is it?     Wood Plank-No Subfloor      Wood Plank-With Subfloor 
                        Tongue & Grove-No Subfloor      Tongue & Grove-With Subfloor 

Does floor flex with traffic?  Yes     No      If yes is movement?  Slight    Moderate   Extreme 

Is floor saturated with oil?  Yes     No 

Are there any chemicals on floor?  Yes     No     If so, what type?

Are Chemicals on floor?   Constantly     Occasionally 

Is floor constantly wet with water?   Yes     No 

What type of manufacturing is performed in this area (if food plant, what foods)?
                                    .

If concrete, can you feel vibration in floor?    Yes     No 

Is vibration from?    Machinery Running     Plant Traffic 
Other (explain):                              .

Is floor movement?   Minimum      Moderate      Extreme 

Are expansion joints or saw cut joints worn?    Yes     No 

If concrete or asphalt, is floor cracked and uneven?    Yes     No 

If Wood Block, is block heaved?    Yes     No 
(If yes, explain):                                           .

What type traffic in plant?    Lift Truck     Pallet Jack     Foot traffic only 
(Other, explain):       .

What type Wheels are on your trucks?    Hard Rubber     Pneumatic Tires     Poly     Steel Wheels 

What do you use to clean plant floors?                                                                                               .

Thank you for taking the time to fill out this form.  This information is needed if we are to help you solve your flooring problem.  We will get back to you within 72 hours, after receipt of this form.  If you need immediate assistance, please call us.

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