Customer Name

Customer Contact

Address

Phone

Fax

Email

Quantity Requested

Please fill in items 1 through 7 to properly specify the fluid which needs to be controlled (please indicate units of measurement)

1) Fluid Type/Chemical Composition or Mixture

2) Gas or Liquid phase?

3) Fluid Temperature Range
( MIN. / MAX. )

4) Fluid Density (if liquid)

5) Fluid Viscosity
(or viscosity range if available)

6) Ambient Temperature Range
( MIN. / MAX. )

7) Is composition constant
(Y/N)?

Please fill in items 8 through 13 to properly specify your flow and pressure requirements (please indicate units of measurement)

8) Flow Rate Range
(MIN. / MAX.)

9) Minimum Inlet Pressure

10) Maximum Inlet Pressure

11) Minimum Outlet
(vent) Pressure

12) Maximum Outlet
(vent) Pressure

13) Minimum Differential
Pressure available

Please fill in items 14 through 20 to specify the controller design and model type

14) Controller Base Material

15) Diaphragm/ Sealing Material

16) Mounting Options

17) Fittings Required

18) Area Classification
(class, division or zone)

19) Outputs (if any) required:

20) Description of Application: