| First Name: |
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Last Name: |
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| Company: |
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Street Address: |
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| City: |
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State: |
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| Zip Code: |
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E-mail Address: |
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| Quote Request: |
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| Service: |
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Product to be Pumped: |
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| Viscocity: |
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Specific Gravity: |
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| Vapor Pressure: |
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Temperature: |
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| Materials in Suspension? |
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If yes, size in inches: |
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| Percentage: |
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Is Product Abrasive? |
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| Capacity (GPM): |
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Pressure (PSI): |
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| Head (Ft.): |
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| If Pressure or Head are Unknown Please Complete the Following: |
| Total Veritcal Rise of Pipe (Ft.): |
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Total Length of Horizontal Piping (Ft.): |
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| Total Number of 90 Degree Elbows: |
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Total Number of 45 Degree Elbows: |
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| Total Number of 'T's: |
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Total Number of Valves: |
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| Specify Type: |
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Any Additional Fittings
(Please be specific): |
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| Pressure Required at End of Pipe (PSI): |
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Suction Conditions
(Please be specific): |
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| Materials of Construction: |
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Advise Pump Type: |
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| Drive |
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| Electric Motor: |
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Speed (RPM): |
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| Phase: |
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Hz.: |
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| Voltage: |
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Enclosure: |
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| Other: |
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Notes: |
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| Comments: |
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