Relays

Following form completion and submittal
we will contact you with a suggested product solution.

General Information
Name *		Required Feilds (*)
Title
Company *
Address
City
State	---- AL AK AR CA DE GA IA IL KS LA MD MI MO MT NH ND NM NY OK PA RI SD TX VT WA WV
Zip Code
Country
Telephone *	ex 616-555-1212
Fax	ex 616-555-1212
Email *

Electrical Data ( Contacts )
Current ( amps )                                                       Voltage
	Lamp					AC		Hz
	Resistive					DC
	Inductive
	Motor	Inrush		Stalled Rotor        Running
	Circuit ------------------ SPST N.O. SPST N.C. SPDT DPDT 3PDT 3PST Other
	Other
	Auxiliary Contacts

Electrical Data ( Coil )
Operating Voltage (nominal)	--------------- 12 VDC 28 VDC 29 VDC 120 VAC 124 VAC Other
Pickup Voltage (max)	------------- 7 VDC 7.5 VDC 9 VDC 9.5 VDC 16 VDC 18 VDC 20 VDC 18 VAC 90 VAC Other		Drop Out Voltage (max)	------------------------ 0.2 to 3 VDC 0.6 to 8.5 VDC 0.5 to 3 VDC 1 to 7 VDC 10 VAC Other
Duty Cycle	------------------ Continuous Intermittent

Environmental Data
Vibration		Hz at		g's
Shock		g's at		duration		Life Cycles
Insulation Resistance milliohms at VDC
Ambient		to		° F Operating
Ambient		to		° F Non-operating
Type Seal	------------------------------------- Hermetically Sealed Environmentally Sealed Gasket Sealed

Envelope

Dimension Height inches         Dimension Width inches       Dimension Length inches

Mounting   --------- Base Top Side                                       Weight ounces

Applicable Specifications

Program / Application

Production Requirements
Estimated production target price			Prototype quantity
Production quantities per year
New requirement			Firm requirement

Description of installation and/or type of equipment the relay will be mouted on