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Company:

Street address:

1. Application:
   
2. Power rating: Watts KW MW
3. Input voltage: VAC VDC
   # of phases:
   Frequency: Hz
4. Output Voltage: VAC VDC
   Current: AMPS
   # of phases:
   Frequency: Hz
5. Type of Load (check all that apply)
   Compressor Fan Transformer Resistive
   Grid Connected Other
6. Software Features:
   
7. Display & Indicator Requirements:
   LED LCD Other
8. Communication Capabilities:
   RS-232 RS-485 Profibus Lonworks Ethernet
   Other
9. Packaging:
   Open Frame Enclosed NEMA type
10. Cooling Method:
    Convection Forced Air Liquid Any
11. Power Connector Type:
    Compression Screw Lug Other
12. Signal Connector Type:
13. Ambient Temperature Range:
    Min. 0C -25C -40C -55C
    Max. 70C 85C 105C 125C
14. Shock & Vibration Specification (if applicable)
    
15. Type of Environment:
    Indoor Outdoor Heavy Pollution Other
16. Prototype date:
    Production date:
17. Allowance for NRE:
    Paid up front Rolled into production Other
18. Expected Yearly Quantities: Initial Annual
19. Agency Approvals Required:
    UL CSA CE IEC Other