Request for Order Form

Brand of Motors

Part #:

Frame Size:

Type of Motor:

Serial #:

HP rating(s):

KW rating(s):

Speed(s):

Number of poles:

Voltages on nameplate:

Cycles on nameplate

Phase on nameplate:

Voltage motor runs at:

Cycle motor runs at:

Inverter Duty

Mounting Requirements

Inverter range in Hz:

Inverter range in RPM

Special Notes regarding this motor (please indicate quantities, special modification required, deliveries needed etc.)

Your Company Name:*

Contact Name:*

Address

City, State/Prov

Contact Number:*

Email:*

Nature of Business:

Type of Gearbox:

Frame Size:

Ratio:

Input Type:

Input Dimensions:

Input Horsepower:

Mounting Requirements:

Dimensions for Mounting:

Output Shaft & Type:

Output Shaft Dimensions:

Output Torque Requirements:

Orientation Requirements:

Type of Application:

Special Features:

Special Notes regarding this motor (please indicate quantities, special modification required, deliveries needed etc.)

Your Company Name:*

Contact Name:*

Address

City, State/Prov

Contact Number:*

Email:*

Nature of Business:

Type of Pump:

Suction Height:

Horsepower:

Voltage:

Flow Requirements:

Speed (rpm):

Prevalence Head:

Pressure Requirements:

Release Pipe Thread Size:

Special Features:

Special Notes regarding this motor (please indicate quantities, special modification required, deliveries needed etc.)

Your Company Name:*

Contact Name:*

Address

City, State/Prov

Contact Number:*

Email:*

Nature of Business: