Date

Company Name

Contact Person

Street Address

City, State, Zip

Delivery Address (if different)

Delivery City/State

Email Address

Phone     Fax

Project Name

EXISTING PUMP INFORMATION

Pump
Make     Model

How has the current pump performed?

Note any specific problems.

Identify the expectations for a successful trial.

APPLICATION DETAILS

Fluid

Flow Required (gallons/minute)

Maximum Pressure PSI

Solids
Are you pumping solids?     No     Yes    If Yes, Approximate Size
Are you pumping non-suspended solids?     No     Yes
Are you pumping suspended solids?     No     Yes

Are you currently using any pumps other than Versa-Matic?     No     Yes
If yes, which ones?    

Number of Units    

Refer to the gold boxes in the chart below to fill in the following information:

Positive Suction Head (ft)		Discharge Head PSI
Liquid Temp S.G. VISC
Suction Lift (ft)	Discharge 2 PSI

Additional Notes or Comments