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Application Request Form
(All Applicable Fields Below Are Required)
Company Name Contact Name
Street Address City
State Zip Code
Country Phone
Fax E-mail
Date (mm/dd/yyyy) Date Required (mm/dd/yyyy)
 
Liquid
Flow Rate
Discharge Pressure (PSIG) kg/cm2
Viscosity Minimum Maximum Normal
Net Inlet Pressure Available (PSIA) Suction Pressure
Pumping Temperature Minimum Maximum
Solids % Size Specific Gravity Ph Level
 
Type of Pump :
Gear Lobe Twin Gear Pump Fuel Pump
 
Materials of Construction :
Cast Iron Ductile Iron (gear only) Steel (screw only)
Stainless Steel Packing Mechanical Seal
 
Relief Valve : yes no
 
Mounting :
Foot Flange
 
Motor Data Requirement :
Enclosure: TEFC Explosion Proof *
Class*  Phase Frequency Voltage
List Other Requirements:
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