Pump Order Form
Please fill out this order form or print and fax or mail to:
125 Spring St.
Port Chester, NY 10573
Fax: (914) 939-3913
Company:
Date:
Contact:
Title:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Ext:
Fax:
E-Mail:
website:
Performance Specs
Pump Head Type
Front (Type 1)
Side (Type 2)
Type of pump:
Single Double (Series
Parallel
)
Flow Rate @ Specified
Pressure/Value
mL/min
LPM
@
Pressure
Vacuume
mm. Hg.
In. Hg.
In. H2O.
Max Vacuume
mm Hg.
In Hg.
H20
Max Pressure
psi.
H20
Pump Current
mA
Life Expectency
Hours
Operating Temp
*C
*F
Pump Motor Voltage
Coreless
BrushType
Duty Cycle
Intermittent
Continuous
hours on
Replacement
New Application (Specify below)
Estimated Production Date:
Estimated Annual Quantities:
Does pump need to restart against Load?:
Yes
No
If "YES" specify load
Aplication:
Additional Comments/Info:
