GENERAL INFORMATIONS
Company:  _________________		Phone nr.: ______________
Fax nr.: ___________________		E-mail: ________________
Contact Ms./Mr.: _____________

Application: _____________________________________________

Temperature:          continous    _____  °C               and/or            max  ____ °C

Liquid to be pumped: ______________________ 
Concentration: _______ %
Density: _____________ (kg/dm3)
Viscosity  Centipoise-cPs/mPas:  _________________

Included particles    [ ] Not   or  [ ] Yes (size mm ______)  weight ______ gr/lt
Abrasive particles?  [ ] Not   or  [ ] Yes

Flow-rate/Capacity:        __________  lts/hr        or          _________  ml/min             
                                     [ ] Fixed                or                  [ ] Adjustable

Self-priming?           [ ] Not   or  [ ] Yes         
Suction head (mts): ______ Delivery head (mts): _____ Total head /mts) ________
Pipe size (mm/”)  _______________ Total pipe length (mts) _________________
Max. pressure (Bar): ________     

Duty cycle: 
[ ] soft (1-20% ON)           [ ] medium (20%-50% ON)          [ ] heavy (50-100% ON)
Estimated working time (hours per day / week): _________

Pump body:                   [ ] Open                 [ ] Close   IP _____
(For drum pumps only – pump tube lenght (cm.) ____________)
Fittings: __________________    Connection tube sizes _____________

Power supply: 	_______ V [ ] single phase [ ] threephase     or  _________ VDC
 [ ] compressed air __________ Bar pressure
IP __________   		Atex:    [ ] Not   or  [ ] Yes class ____________________

Estimated needed quantity:  ______ pcs (per order)   ______  pcs (per year)

Special features (FDA, USP, ….....):  ________________________________

NOTES / SPECIAL QUESTIONS: ______________________________________

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