Please provide the following contact information:

Contact Information

	Name
	Title
	Company
	Address
	City, State Zip	,
	Phone
	Fax
	Email Address

Product Information and Operating Conditions

Product

Specific Gravity

Temperature (^oF)

Flow Rate (GPM)

Viscosity (Cpa)

*Suction Conditions*
Suction Pressure (NPSHA)

*Discharge Conditions*
Discharge Pressure (PSIG)

Static Head (FT)

Tubing Outside Diameter (in)

Length of Tubing (FT)

Other Equipment Installed After Pump

Number of Elbows Installed

Number of Tees Installed

*CIP Conditions*
Will This be a CIP Service?
	Yes No
CIP Flow Rate (GPM)

CIP Discharge Pressure (PSIG)

CIP Temperature (^oF)

CIP Flow Rate (GPM)

How Will Pump Be Used in CIP Loop?
	Pump will not be used Pump will be used as supply pump Pump will be used as return pump
*Seal Selection*
Type of Seals
	Single Mechanical Single Mechanical-Flushed Double Mechanical
Seal Faces
	Carbon/Stainless (C/SP Only) Carbon/Silicon Carbide SC/SC
Elastomers
	EPDM Viton Nitrile Other (Specify)
*Options Selection*
Casing Drain
	Yes No
Leg Assembly
	StSt Mild Steel No Leg Assembly
HPW Flush Piping
	Yes No
Surface Finish

Connection Types
	Tri-Clamp Other (Specify)
*Motor Selection*
Enclosure
	TEFC Washdown X-Proof Inverter Duty Other (Specify)
AC Inverter
	Yes No
*Traceability Selection*
Material Traceability
	No Certificate of Conformance 3.1b Traceability* *Available on LKHU, SRU and SX Only
*Other Requirements Selection*
Special Requirements

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