Date Company

Name/Title Title

Address

City State Zip

Phone/Fax  E-Mail

1.  SOLUTION TO BE PUMPED:
(a) Chemical & Concentration

(b) Abrasive or solids in suspension yes  no

(c) Liquid temperature range

(d) Specific gravity

(e) Viscosity

2.  FLOW RATE REQUIRED at psi or at feet head

3.  STYLE PUMP DESIRED

4.  INLET SIZE AND SHAPE

5.  FLOODED INLET? yes  no

If "no," how high must pump lift? ft.

6.  OUTLET SIZE AND SHAPE

7.  POSITION OF PUMP: Horizontal  Vertical

8.  DUTY CYCLE:  Intermittent  Continuous

9.  TYPE POWER: 
(a) ELECTRICAL:
Volts   Cycle   Phase   Motor Type

(b)  AIR (Pneumatic):
PSI available   CFM available   Lubricated?  yes   no 

10.  ENVIRONMENT:
Indoors  Outdoors  Submersed

11.  REPLACING EXISTING PUMP?  yes  no
If "yes," reason?

Current brand Model HP

Inlet size   Outlet size
Other Information

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