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. Heat zones to be controlled: 1 2 3 4 5 6 7 8 3. Available voltage: VAC 4. Available maximum amperage: AMPS 5. Temperature sensor type: RTD T/C J T/C K Other Sensor 6. Housing type and environment: Indoors Outdoors - NEMA 4X 7. Misc. notes:

© 2005 The Conrad Company. All rights reserved • Phone: 614-864-3971 • Fax: 614-759-4912 • Email:  sales@conrad-co.com