Request Quotation

Submit any one of three ways
Online Fax Phone
Unavailable!
Sorry for the inconvenience. 		Fill out the form below, print it and then fax it to:
1 (860) 974 - 0691 (Outside US)
1 (800) 974 - 3668 (US Only)		 Call one of our Customer Service Representatives at:
1 (860) 974 - 1000

In order to submit an accurate Quotation to you, please complete all Required Informational Sections in full.

Required Informational Sections will be marked with an "(R)"
- Required Informational Fields will be marked with an "*"

Optional Informational Sections will be marked with an  "(O)"
- Optional Informational Fields left blank or unselected will indicate acceptance of the Standard Model's Specification

CONTACT INFORMATION (R)

Prefix *Name Suffix

BUSINESS INFORMATION (R)

*Business
Name
*Mailing
Address		 *
*City *State
or
Province

*Postal
Code		 *Country

 

*Telephone

Facsimile
*E-mail

INTENDED APPLICATION (R)

*Intended
Application
Notes

BASED ON CATALOG STANDARD (R)

*Standard
Model
*Quantity(s) 500+                100-199           20-49            5-9
200-499          50-99                10-19            2-4
Other
Notes

OPTIONAL SPECIFICATIONS SECTION

EXTERIOR APPEARANCE (O)

(If modifications to the Standard Model's Exterior are required, please complete this section.)

Exterior Color    Standard Model       Other*  
     *  Please reference - Pantone Color Formula, RAL 841 GL Design System or FED-STD-595A Number
Exterior Texture Standard Model       Other
   Guarded                Nameplate

Packaging         Warning Labels

Notes:

CORDSET REQUIREMENTS (O)

(If modifications(Add/Change/Delete) to the Standard Model's Cordset are required, please complete this section.)

Cordset
Plug
Other
CORD
Manufacturer
Name		 Mfg. Item
No
Gauge No. of Conductors
Color Length
Shield
STRAIN RELIEF
Manufacturer
Name		 Mfg. Item
No
PLUG or CONNECTOR 
Manufacturer
Name		 Mfg. Item
No
Backshell Connector
Terminal
Type
- - - - - - - - - - - - -    Stripping plug-end (w/o plug)   - - - - - - - - - - - - -
Outer Jacket
Length		 Inner Lead
Length		      Tinned
Direct Wire Terminal Type
Notes

TESTING REQUIREMENTS (O)

(If modifications to the Standard Model's Testing Requirements are required, please complete this section.)

Notes:

POWER REQUIREMENTS (O)

(If modifications to the Standard Model's Power Requirements are required, please note here.)

Notes

INTERIOR REQUIREMENTS (O)

(If modifications to the Standard Model's Interior Requirements are required, please complete this section.)

# of Poles Double Break      Solid State      Reed Switch
Snap Action      Silent     Auxiliary Switch
Gold Contact      Splash Proof      Water Proof
Potentiometer      Ohms     Watts
Notes

MISCELLANEOUS REQUIREMENTS (O)

(If modifications to the Standard Model's Certifications are required, please complete this section.)

UL Recognized Component Mark for Canada and the United States      UL Mark for Canada and the United States      CSA Certified      DEMKO Recognized Component      TUV BAUART      SEV Accepted      CE Conformity Mark

NEMA        IP

Notes

SPECIAL NOTES AND INSTRUCTIONS (O)

(If other modifications to the Standard Model are required, please complete this section.)