First Name:* 
									
									
									
									
										Last Name:* 
									
									
									
									
										Company Name:* 
									
									
									
									
										Email Address:* 
									
									
									
									
										Address: 
									
																		
									
									
										City: 
									
									
									
									
										State (USA and Canada): 
									
									
										
											
				                              Select One 
				                              Not US or Canada 
				                              Alabama 
				                              Alaska 
				                              Alberta, Canada 
				                              American Samoa 
				                              Arizona 
				                              Arkansas 
				                              British Columbia, Canada 
				                              California 
				                              Colorado 
				                              Connecticut 
				                              Delaware 
				                              Federated States of Micronesia 
				                              Florida 
				                              Georgia 
				                              Guam 
				                              Hawaii 
				                              Idaho 
				                              Illinois 
				                              Indiana 
				                              Iowa 
				                              Kansas 
				                              Kentucky 
				                              Louisiana 
				                              Maine 
				                              Manitoba, Canada 
				                              Marshall Islands 
				                              Maryland 
				                              Massachusetts 
				                              Michigan 
				                              Minnesota 
				                              Mississippi 
				                              Missouri 
				                              Montana 
				                              Nebraska 
				                              Nevada 
				                              New Brunswick, Canada 
				                              New Hampshire 
				                              New Jersey 
				                              New Mexico 
				                              New York 
				                              Newfoundland, Canada 
				                              North Carolina 
				                              North Dakota 
				                              Northern Mariana Islands 
				                              Northwest Territories, Canada 
				                              Nova Scotia, Canada 
				                              Ohio 
				                              Oklahoma 
				                              Ontario, Canada 
				                              Oregon 
				                              Palau 
				                              Pennsylvania 
				                              Prince Edward Island, Canada 
				                              Puerto Rico 
				                              Quebec, Canada 
				                              Rhode Island 
				                              Saskatchewan, Canada 
				                              South Carolina 
				                              South Dakota 
				                              Tennessee 
				                              Texas 
				                              Unknown 
				                              Utah 
				                              Vermont 
				                              Virgin Islands 
				                              Virginia 
				                              Washington 
				                              Washington, DC 
				                              West Virginia 
				                              Wisconsin 
				                              Wyoming 
				                              Yukon, Canada 
				                            
										
									 
									
									
										Zip: 
									
									
									
									
										Phone: 
									
									
									
									
										Fax: 
									
									
									
									
										Product Family 
									
									
										
											
				                              Select One 
				                              Time Delay Relay 
				                              AC Voltage Sensor 
				                              DC Voltage Sensor 
				                              Phase Sensor 
				                              Frequency Sensor 
				                              Current Sensor 
											  Power Monitor 
											  Flasher 
											  Electro-Mechanical Relay 
											  Solid State Relay 
											  Other 
											 
										
										
									 
									
									
										Input Voltage 
									
									
										
											
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												28 VDC 
												115 VAC Single Phase 
												220 VAC Single Phase 
												115/208 VAC Three (3) Phase 
												Other 
											   
										
									 
									
									
										Input Frequency 
									
									
										
											
												Select One 
												DC (not applicable) 
												60 Hz 
												400 Hz 
												50/60 Hz 
												47-440 Hz 
												Other 
											   											
										
									 
									
									
										Contact Arrangement 
									
									
										
											
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												SPDT 
												DPDT 
												3PDT 
												4PDT 												
												Other 
											   												
										
									 
									
									
										Contact Current Rating 
									
									
										
											
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												2 Amp 
												5 Amp 
												10 Amp 
												25 Amp 												
												Other 
											   											
										
									 
									
									
										Operating Temperature Range 
									
									
										
											
												Select One 
												0-71° C 
												-40 to 85° C 
												-55 to 125° C 								
												Other 
											   	
										
									 
									
									
										Case Size or Weight Requirements 
									
									
									
									
										Mounting Arrangement (bracket, stud, socket, other) 
									
									
									
									
										Terminal Type (solder hook, circular connector, terminal block, plug-in) 
									
									
									
									
										Other Electric Characteristics, Specifications or Information (such as Time Delay, Voltage, Phase, Frequency or Current Range, etc) 
									
									
									
									
									
									
									
									
									
									
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