Application Information Form
Please take a moment to complete all information below to ensure timely and accurate service.
Date: ________________________________________________
Name _______________________________________________________________________________________
*Company: ________________________________________________________________________________________
*Address 1: ________________________________________________________________________________________
*Address 2: _________________________________________________________________________________________
*City, State, Zip: _________________________________________________________________________________________
+Phone, FAX, E-Mail: _________________________________________________________________________________________
1. Function
1.1 Mode of Operation:
_________________________________________________________________________________
__________________________________________________________________________________
1.2 Time Delay (please circle all that apply)
1.2.1 Delay #1 seconds / minutes / hours
MIN ____
TOLERANCE +/- 1% /2% /5%
MAX ____
1.2.2 Delay #2 seconds / minutes / hours
MIN ____
10% /20% /30% /other ___________
TOLERANCE +/- 1% /2% /5%
MAX ____
10% /20% /30% /other __________
2. Input Power (please circle all that apply)
2.1 Nominal Voltage 12VDC / 24VDC / 110VDC / 24VAC / 120VAC / 230VAC / 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 / Battery / Generator / Solar cell / Other please specify:________________________
( If your selection is AC Line or AC Power Supply): single phase or 3-phase
2.4 DC Type: regulated DC / filtered DC / unfiltered DC / Other Please Specify:_____________
3. Output (please circle all that apply)
3.1 Type solid state / mechanical relay / Both / Other Please Specify:______________
3.2 Form: SPST / SPDT / DPST / DPDT / Other Please Specify:______________
(If SPST Specify: N.O. / N.C.)
3.3 Load Rating: Amps / Watts / Horse Power / Other or Multiple Please Specify:_________________________________________
3.4 Type of Load: Brush Motor / Solenoid / Relay Coil / Solid State Input / AC Induction Motor / AC Shaded Pole Motor
Incandescent Lamp / Transformer / Other or Multiple Please Specify:___________________________________@________ volts
4. Environmental Conditions
5. Package Style: (please circle)
8 pin round plug-in / 11 pin round plug-in / 11 pin blade plug-in / none / 2x2 (cube) / 2x3 (cube+1)
LP30 (flat pack) / PM2425 wall plug / Other Please Specify: _____________________________________________
Encapsulation: conformal coated / urethane potted
6. Termination Preference: (Please circle)
wire leads / standard 3/16” male QC terminals / standard 1/4” male QC terminals / plug-in base
Other please specify:______________________________
7. Potential
7.1 Prototype Requirements:
Number of pieces _____________________________
Date Required _____________________________
7.2 Pre-Production Requirements:
Number of pieces _____________________________
Date Required _____________________________
7.3 Production –
Estimated Annual Usage ______________________
Price Objective(s) ______________________
Date Required ______________________
8. Required Agency Approvals: (please circle)
UL / CUL / TUV / CE / Other or Multiple Please Specify:____________________________________
9. Other Information:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________