Application Request Form
All Applicable Fields Below Are Required

Company Name:		Contact Name:
Street Address:		City:
State:		Zip Code :
Country:		Phone:
Fax:		E-mail:
Date:		Date Required :
Liquid:
Flow Rate :
Discharge Pressure (PSIG)
Viscosity:	Minimum      Maximum      Normal
Net Inlet Pressure Available (PSIA)		Suction Pressure:
Pumping Temperature:	Minimum    Maximum
Solids:  %    Size        Specific Gravity:             Ph Level:
Type of Pump:
Gear    Progressive Cavity   Lobe    Screw
Materials of Construction:
Cast Iron   Ductile Iron (gear only)  Steel (screw only)    Stainless Steel
Packing    Mechanical Seal
Relief Valve:    yes    no
Mounting:
Foot   Flange  CCD (3600)    Hydraulic Drive
Motor Data (Must be completed if motor is to be supplied by Roper Pump Company)
Enclosure: ODP     TEFC    Explosion Proof *
Class *      Group * (reply to these if you have checked explosion proof)
Phase      Frequency      Voltage
List Other Requirements:
After the submission of this form you will be returned to our home page. Thank You!