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Available to MSA Sales Associates ONLY
Sample Request Form
For Protective Eyewear, Hearing Protection
Hardhats & Accessories (Valid in North America Only)
Protective Eyewear
Hearing Protection
See Other Side For More Products
This form must be clearly and completely filled out:
Requested by:
Ship to:
Address:
Address:
Phone:
Hardhats & Accessories
Fax:
Phone:
Region:
5
Fax:
E-mail address:
MSA Sales Associate:
Note: Please limit individual orders to a maximum of 6 pieces of each part number. Only items on this form may be ordered. No specials.
Please fax or mail this form to:
MSA Fulfillment Center, c/o Cyndie Hart, Hart Printing and Lithographing Co., 30 Terminal Way, Pittsburgh, PA 15219
Phone (412) 481-9100 • Fax (412) 481-9625
Protective Eyewear & Cleaning Accessories
MSA Part # Description
Quantity
MSA Part # Description
Quantity
697514 Arctic™, clear lens
10041818 Alpine™, clear lens, clear frame
697515 Arctic, gray lens
10041820 Alpine, gray lens, black frame
10038845 Arctic Elite, clear AF lens
10041823 Alpine, indoor/outdoor lens, black frame
10038846 Arctic Elite, gray AF lens
10018662 Sierra™, black frame w/clear A/F lens
10026005 Aurora™, black frame, clear AF lens
10010570 Sierra, black frame w/gray lens
10026006 Aurora, black frame, gray AF lens
697550 Sierra, black frame, clear lens
10026007 Aurora, black frame, amber AF lens
10012842 Sierra, red/white/blue frame w/clear lens
10026008 Aurora, black frame, blue-mirrored lens
10018440 Sierra small faces, black frame, clear lens
10033740 Pyrenees, black frame, amber AF lens
10022087 Pre-Moistened Towelettes (box of 100)
10033716 Pyrenees, black frame, clear lens
10065848 Voyager, clear lens
10033717 Pyrenees, black frame, gray lens
10065850 Voyager, gray lens
10033719 Pyrenees, black frame, gray AF lens
10065892 Voyager, indoor-outdoor lens
10065847 Mag 2.0 Diopter, black frame, clear lens
10070914 Vista™, metal gray temple, clear lens
10079246 NFL Safety Glasses, Chicago Bears, gray lens
10070915 Vista, metal gray temple, gray lens
10079249 NFL Safety Glasses, Dallas Cowboys, gray lens
10070916 Vista, brown copper temple, indoor/outdoor mirrored lens
10079252 NFL Safety Glasses, Green Bay Packers, gray lens
10070917 Easy-Flex, blue-gray frame, clear lens
10079257 NFL Safety Glasses, Miami Dolphins, gray lens
10070918 Easy-Flex, blue-gray frame, gray lens
10079259 NFL Safety Glasses, New England Patriots, gray lens
10070919 Easy-Flex, blue-gray frame, amber lens
10079261 NFL Safety Glasses, New York Giants, gray lens
10070921 Easy-Flex, metallic sand frame, “sky orange” mirror lens
10079263 NFL Safety Glasses, Oakland Raiders, gray lens
10002545 Tradewind™, black frame, clear lens
10079265 NFL Safety Glasses, Pittsburgh Steelers, gray lens
10008175 Rx Overglasses, clear antifog lens
10012855 Rx Overglasses, gray antifog lens
10008177 Impression™, clear, antifog lens
10008178 Impression, gray, antifog lens
Voyager™ Protective Eyewear
Easy-Flex™ Protective Eyewear
MAG™ Protective Eyewear
Pyrenees™ Protective Eyewear
Available to MSA Sales Associates ONLY
Sample Request Form
For Protective Eyewear, Hearing Protection
Hardhats & Accessories (Valid in North America Only)
Protective Eyewear
Hearing Protection
Hardhats & Accessories
This form must be clearly and completely filled out:
Requested by:
Ship to:
Address:
Address:
Phone:
Fax:
Phone:
Region:
Fax:
E-mail address:
MSA Sales Associate:
Note: Please limit individual orders to a maximum of 6 pieces of each part number. Only items on this form may be ordered. No specials.
Please fax or mail this form to:
MSA Fulfillment Center, c/o Cyndie Hart, Hart Printing and Lithographing Co., 30 Terminal Way, Pittsburgh, PA 15219
Phone (412) 481-9100 • Fax (412) 481-9625
Head Protection and Accessories
Hearing Protection, continued
MSA Part #
475358
10034027
10033652
459458
10074067
MSA Part #
10087436
10087429
10087422
10061123
697290
697410
10036456
468771
Description
Quantity
White, V-Gard® cap with ratchet
White, V-Gard Advance™, (6-point suspension)
Bump Cap, plastic, white
Goggle retainer for caps
White, SmoothDome® Cap with
Fas-Trac suspension
1-Touch® Replacement Suspension
for standard size V-Gard®
Sun Shade for standard V-Gard® cap
Sun Shade for standard V-Gard hat
Plastic, Instant Release, complete with lugs
Lugs only for slotted caps to accept
Quick-Disconnect attachment accessories
696823DVD-MC Proper Use & Care of MSA Protective Helmets DVD
Hearing Protection
MSA Part #
10061271
10061272
10061229
10061535
10026398
10061273
10004291
10034487
10009333
10051348
10003344
10051347
Description
Quantity
HPE Headband model (NRR 26dB)
HPE Cap mounted model (NRR 27dB)
EXC Headband model (NRR 24dB)
XLS Cap mounted model (NRR 23dB)
Sound Blocker™ 26 Earmuff Kit
(NRR 26) for Defender Frame
Multi-Position Muff (NRR 25)
Economuff™ Earmuff (NRR 20)
Soprano Muff for hats (NRR 25)
FormFit™ Plugs, box of 200 (NRR 29) (non-corded)
FormFit disposable molded urethane foam
ear plugs, (non-corded) box of 200 pair (NRR 31)
Comfort Band (NRR 23)
FormFit disposable molded urethane foam earplugs
(corded). Box 0f 200 pair (NRR 31)
Description
Quantity
left/RIGHT, LOW, white, headband mode
left/RIGHT, MEDIUM, blue, helmet-mounted
left/RIGHT, HIGH, yellow, helmet-mounted
Face Protection
MSA Part # Description
Quantity
10021616 Defender® Faceshield Frame for
all slotted caps (no lockdown)
10037098 Defender Faceshield Frame, with male
Instant Release Attachment less lugs
488131 Polycarbonate Visor, Clear: 8” x 16” x .040” (Formed)
488132 Polycarbonate Visor, Clear: 8” x1 16” x .060” (Formed)
10005883 Propionate Visor, Clear: 8” x 15 /2” 1x .060” (Formed)
10017934 Polycarbonate Visor, Clear: 8” x 15 /2” x .040” (Flat)
10063106 Polycarbonate Visor, Clear: 10” x 20”
1 x .070” (Molded)
10005882 Propionate Visor, Shade 5: 8” x 15 /2” x .060” (Z87 Basic)
10021611 Defender headgear, ratchet
10021610 Defender headgear, pin lock
10080794 Orange Chip Arrester for use with Defender+
Easy Release Frame
10021614 Defender Faceshield Frame for
standard-sized V-Gard® caps (with lockdown)
10021615 Defender Faceshield Frame for
Topgard® caps (with lockdown)
10080783 Defender+ Easy Release muff frame,
black, for V-Gard/Smooth Dome
(for use with MSA muffs for slotted caps)
10021616 Defender+ Faceshield Frame for
slotted caps, (without lockdown)
488159 Metal Foldback Faceshield Frame for Hat
488160 Metal Foldback Faceshield Frame for Cap
10079072 Skullgard® Metal Foldback Faceshield Frame
5555-133-MC / Jun 2008