Customer Information

Customer:

Attention:

Address:

City:

Province/State:

ZIP/Postal Code:

Phone:

Fax:

Cell:

E-mail:

Sales Contact:

Site Location:

Site LSD:

Pump Design Info

Make:      Model:
Duplex   Triplex   Quintuplex
RPM:   Stroke:   Bore:
Connection Type: Flanged   Threaded
   Suction Pressure: FT PSI kPa          Suction Line Size:      Flange Rating if Applicable: #ANSI
Discharge Pressure: FT PSI kPa      Discharge Line Size:      Flange Rating if Applicable: #ANSI
What kind of fluid is being pumped?
End destination of stabilizers (what country):

Delivery Options

Delivery Date Requested: YY/MM/DD	Trucking:  WSS   Other
	Loading:   WSS   Other

Finance Options

Purchase    Lease to Purchase    Rent

Other Options or Comments