Engineering Evaluation Request (Lasetec EVR)

Please fill in the form completely.  If you have questions regarding the use of this form, please contact EVR@filtec.com

	Required fields in Red.
	Submitter Name:
	Submitter Email Address:
	Customer:
	Customer Location:
	Customer Contact:
	Address:
	City, State, Zip:
	Country:
	Phone:
	Fax:
	Sales Person:
	Date needed:	mm/dd/yyyy
	Potential Quantity of Machines:
	Samples Shipped?	Yes    No
	Receiving Record# (If already received)
	Industry (Note: If industry is not listed, please contact Lasetec Coding Team)	Select One Beverage Chemical Cosmetic Food Personal Health Care Pharmaceutical Other:
	For replacement of existing machine(s), please provide the following information:
	Manufacturer:
	Product Model/Number:
	Reason for replacing:
	Request Type:	Marking Samples  Modification to Machine
	Marking location (Please select one as applicable): Filler: Before  Inside  After Labeler: Before  Inside  After Packer: Before  Inside  After Other:     Before  Inside  After If Laser will be mounted inside machine: Make: Model: Serial#:     Product Information:   Container Contents: Material type to be marked: Container Rate: containers per minute Unit of Measure inch       mm Gap: Width (package width in direction of flow) (see chart below) Is Gap fixed? Yes       No       Pitch: Conveyor Speed:    Code Requirements:   Number of Character per line: Number of Lines: Maximum number of character required? Minimum acceptable character height: Maximum acceptable code length: Code quality: Consumer Code (high contrast)    Factory Traceable Description of line and product motion, or desired modification: Attach a file: