Customer Name: Address: City: State: Zip: Phone: Fax: E-mail Address: Contact: 1. Description of application (include type of equipment plus description of system): 2. Operating temperature: 3. Overall dimensions: Length Width Height 4. Vessel General Shape Rectangular Square Circular Triangular Other 5. Thermal insulation thickness 1/2" 1" 2" 6. Heater requirements: Volts: Watts: Phase: 1 3 7. Temperature sensor: RTD T/C J T/C K Other Sensor Qty: 8. Leadwire Length: Inches 9. Misc. notes:

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