Full Name:

Email:

Company:

Title:

Phone:

Fax:

Address:

State/Province:

Postal Code:

Telephone:

Existing Pump serial number and model number application

Capacity required:
(U.S.G.P.M.)

Suction:
(Head, Lift, ft., PSIA):

Total Dynamic Head (*)
Total discharge head minus total suction head or plus total suction lift:

NPSH available at pumping temp. (ft):

Discharge (Head):

Fluid to be pumped:

If mixture, state percentage of each substance by weight:

Solids in suspension, if any:
(state types)

Largest particle: Abrasive qualities: Average particle: Quantity of solids:

Pumped fluid temp:
(°F)

Vapor pressure:

At start up: At pumping Temp:

Specific gravity:

Viscosity:
(cps)

Any other pertinent data:

Preferred materials of construction:

Design pressure:
(psi)

Types of connections:

Cooling water availble:

Motor characteristics required:

Special features required, if any:

Test and/or inspection requirements:

Additional Information: