Safety Brush Order Form

CUSTOMER INFORMATION Customer Name:

Region:

Order Date:

/ /

Ship Date:

/ /

Branch ID #:

Service Order/ Contract #:

UNIT INFORMATION Escalator Make:

Escalator Model:

Balustrade:

Escalator Rise:

Inches* mm*

Escalator Degrees:

degrees

* If you don't know your exact rise, fill out a D-Flector Field Survey Form to calculate the proper dimensions and submit in addition to this order form
# of D-Flector Kits Required**:

Brush Holder Finish:

** Use a new order form for any additional escalators that are not the same make, model and rise as indicated above

OTHER PRODUCTS

Handrail Cleaner:

Quantity:

Handrail Polish:

Quantity:

RapidRail Installation Tool

Quantity:

CONTACT INFORMATION Invoice Address:

Ship Here
Ship To Address:

Ship Here
Ship VIA:

Requester's Name:

Title:

Email Address:

Telephone #:

Fax #:

Notes:

Box Markings:

Please confirm my order by:

Encuentre un Distribuidor Local

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OEM Engineered Safety Brushes

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