Name

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

FAX

E-mail*

webpage/URL

Description of Application

Horsepower or Kilowatts 

Rpm (in/out) or Ratio

Duty Cycle, Starts per Hour

    Percent Running Time 

Service Factor or AGMA Class 

Overhung Load (input)

     (output) 

Operating Environment

Ambient Temperature Range

Shaft Arrangement 

inline right angle        Gearing Type  spur helical planetary bevel spiral bevel worm

Mounting Type and Arrangement  

Target Cost per Unit 

Quantity per Year  

    Release Quantity 

Format for attachments
(sketchs, etc.):