Application Information Form
Please take a moment to complete all information below to ensure timely and accurate service.
*Name:
*Company:
Title:
*Address 1:
Address 2:
*City:
*State:
*Zip:
+Phone:
+Fax:
E-mail:
+
Please include country code and area code
*
Required fields
1. Function
1.1 Mode of Operation:
1.2 Time Delay
1.2.1 Delay #1
Please Select One
Seconds
Minutes
Hours
MIN
/MAX
TOLERANCE +/-
1%
2%
5%
10%
20%
30%
Other
1.2.2 Delay #2
Please Select One
Seconds
Minutes
Hours
MIN
/MAX
TOLERANCE +/-
1%
2%
5%
10%
20%
30%
Other
2. Input Power
2.1 Nominal Voltage
Please Select
12VDC
24VDC
110VDC
24VAC
120VAC
230VAC
Other
Other Please Specify
2.2 Tolerance
5%
10%
15%
20%
2.3 Frequency (Hz)
50/60
50
60
120
400
Other
None (DC)
Power Source:
AC Line
AC Power Supply
DC Power Supply
Battery
Generator
Solar Cell
Other
Other Please Specify
If your selection is AC Line or AC Power Supply
Please Select One
Single Phase
3 - Phase
2.4 DC Type:
Please Select
Regulated DC
Filtered DC
Unfiltered DC
Other
Other Please Specify
3. Output
3.1 Type
Please Select
Solid State
Mechanical Relay
Both
Other
Other or Both Please Specify
3.2 Form
Please Select
SPST
SPDT
DPST
DPDT
Other
Other Please Specify
If SPST Specify
Please Select
N.O.
N.C.
3.3 Load Rating
Please Select
AMPS
WATTS
HORSE POWER
MUTLIPLE
Other
Other or Multiple Please Specify
3.4 Type of Load
Please Select
Brush Motor
Solenoid
Relay Coil
Solid State Input
AC Induction Motor
AC Shaded Pole Motor
Incandecent Lamp
Transformer
Other
Multiple
Other or Multiple Please Specify
@
Volts
4. Environmental Conditions
5. Package Style:
Please Select
8 Pin Round Plug-in
11 Pin Round Plug-in
11 Pin Blade Plug-in
None (Open Board)
2x2 (Cube)
2x3 (Cube + 1.")
LP30 (Flat Pack)
LP50 (Flat Pack)
PM2425 (Wall Plug)
Other
Other Please Specify
Encapsulation
Please Select
Conformal Coated
Urethane Potted
6. Termination Preference
Please Select
Wire Leads
Standard 3/16" Male QC terminals
Standard 1/4" Male QC terminals
Plug-in Base
if "other" is chosen please specify
7. Potential
7.1 Prototype Requirements:
pieces
Date Required
7.2 Pre-Production Requirements:
pieces
Date Required
7.3 Production - Estimated Annual Usage
Price Objective(s)
Date Required
8. Required Agency Approvals
Please select
UL
cUL
TUV
CE
All of the Above
Other
Multiple
None
Other or Multiple Please Specify
9. Other Information:
