1. Your Name
2. Company Name
3. Your Email
4. Your Phone No.

1. Product Name or ID No.

    

2. Product Shape (choose one)

     > Shape < Sphere Tablet Bi-Convex Bisect(s) Oval Caplet Capsule Other
3.   If other shape, please describe here.

4. Product Surface (choose one)

     > Surface < Sugar Coated Enteric Coated Film Coated Gelatin Other
5.   If other surface coating, please describe here.

6. Surface Finish

   Waxed
7. Wax Type
8. Amount applied per 100Kg
9. Clear Coat
10. Sealing Coat Comp.
11. Other
12. If other finish, please describe here.

13. Product Dimensions and Tolerances (and Batch Deviations)

    Diameter ±
14. Length ±
15. Width ±
16. Thickness ±
17. Belly Band ±

1. Has An Ink Been Specified?

   Yes
2. If "Yes", Manufacturer
3. Color
4. Ink ID Number
5. No

6. Print Style - Tablets and Capsules

      > Print Style - Tabs and Caps < One Side Printing Two Side Printing One Color Printing Multi-Color Printing

7. Print Style - Capsules, Only

      > Print Style - Capsules < Rectified Linear Spin Print

8. Logo Artwork (choose one)

      > Logo Artwork < Customer Supplied Electronic file available Needs to be created

9. Has a Font Style Been Chosen?

   Yes
10.  
11. No

12. Production Requirements

    Projected Volumes/Year
13. Required Output per Hour/Shift > Choose One < 0-100,000 0-250,000 0-1,000,000
14. Batch Size

15. Type of Development Product Supplied to Ackley:

       > Product Type < Actual Placebo Pilot Batch

(The development product should always be the ACTUAL product that will be used in production. Ackley Machine Corporation will only warrant the equipment's function with the product submitted for production development.)