Sample Request Form (Application Information)

 

Date:
Company:
Street Address:

City:
State/prov.:

Zip:

Country
Requested By:
Title:
Fax:
Phone:
E-mail:
Additional Contact
Title:
Fax:
Phone:
E-mail:

Application

APPLICATION DESCRIPTION/DETAILS


Application Is:
New Product Existing Product

Thermostat Function:
High Limit Protector Temperature Control Overcurrent Protector

Motor Protector
Motor Type

Transformer Protector
Located in: Primary Secondary

Maximum Ambient Temperature Exposure (in Degrees Centigrade)
Duration(Minutes)

Rate of Temperature Rise If Known (in Degrees Centigrade/Minute)

Environmental Conditions: Chemical Dust Humidity Vapor

Explain

Electrical Requirements: xxApplied Voltage
AC DC
Amperage Resistive Inductive
FLA LRA

Thermostat Specifications:

    Contacts Open Circuit on Temperature Rise (Normally Closed)
    Contacts Close Circuit on Temperature Rise (Normally Open)

Calibration Temperature Required °C± °C Tolerance
Reset Temperature Desired °C

Lead Wires: Length Required (in Inches) Lead#1 Lead#2

Wire Gauge
Insulation Type
Temperature Rating Required

Thermostat Insulating Sleeve: Mylar Nomex Other None Required

Thermostat/Thermal Protector Models:

Samples: Pieces Required:
Date Required

Production: Estimated Annual Usage
Typical Order Quantity

Agency Approvals Required: UL CSA VDE Others

Quotation Required If Yes, Quantity:

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