Contact Name: Company Name:
Address:
City: State Abbrev: Postal Code: Country:
Phone Number: Fax Number:
E-mail:

Full or Partial Part Number:
Top Plate Size: Bolt Hole Spacing: Overall Height:
Wheel Type: Wheel Diameter:
Wheel Face Width: Wheel Hub Length:
Options (Brakes, Seals, etc.):
Maximum Weight of Unit (fully loaded): Maximum Weight per Caster:

Current Floor Material: Floor Condition: Excellent Good Fair Poor
Special Environmental Conditions (oil, salt, etc.):
Temperatures: High (over 120°F) Medium (between 20-120°F) Low (under 20°F)
Shock Loads: Yes No
Side Thrusts: Yes No
Towed Operation: Yes No
Frequency of Use:

Quantity 1:
Quantity 2:
Quantity 3: