Please complete the form below and one of our representatives will contact you shortly. Name: Title: Company Name: Address: Address: City: State: Postal Code: Country: Application Information Telephone: Mobile: Fax: Email: Website: EAU: Drawing/Part#: Description of application: Mechanism driven by output shaft: New or existing Is the unit available for testing? If existing, who is the current supplier: Yes No Any problems or concerns with current supplier? Currently in production?: Yes No If no, estimated time to production: Performance Requirements Voltage: Voltage range: Frequenzy Hz: 60 50 50/60 Output torque determined by: Start torque: Run torque: No load RPM: RPM under load: Will the gearmotor be installed: Yes Environmental Conditions Ambient temperature: Full enclosure: No degrees Humidity level: Corrosives: Other information about the motor location: Duty Cycle Maximum run time: Minimum time off: Number of cycles per hour: Minimum life required (cycles or hours): Output Shaft Requirements Direction of shaft rotation: CW Shaft OD: CCW Shaft detail: Viewed from: Cover side: Motor side: Shaft material: Shaft extension from mounting surface: Cover side: Case (or motor) side: Overhung Load? Yes No Describe: Axial Thrust Load? Yes No Braking Requirements Is a brake required? Will the brake hold the load? Agency Requirements UL CSA CE Yes Yes Other Describe: No No Allowable over travel: If so, how much? degrees Detail for other: