Application Request Form

    All Fields With * Must Be Completed

    Personal Information



    Pump Information

    Pump Style


    Pump Specification

    Motor Specification

    Check All That Apply

    115 VAC208 VAC230 VAC460 VAC480 VAC575 VACOther (Explain)

    Speed Control

    Motor Enclosures

    Currently Using

    *Pictures of the pump and motor labels may be requested during the quote process, if you have a picture(s) please attach to this Application Form. If the file is too large please send to and put "Application Picture [todays date]" in the subject field.

    Additional Comments/Information