General Information:

Name

Company 

Address 

City      State  Choose A State Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE District of Columbia - DC Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN IOWA - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Missisippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY    Zip Code 

Phone Number     Fax Number  

e-mail address 

Fan Application:

Air        Gas         Material            Corrosive          Explosive 

Describe your fan application.  Please be sure to include whether this fan will be used for ventilation or exhaust and whether the airstream will be clean or dirty?  Also, briefly describe the system that it will be used with.

Please fill in the following to the best of your ability.

Airflow     Choose an Airflow ACFM SCFM PPH   Static Pressure  

Is resistance to airflow on the suction side or discharge side of the fan?

Suction Side       Discharge Side       Split between suction and discharge. 

if the above box is checked, please provide the percentage of both below

Suction %   Discharge % 

Temperature  Degrees F Degrees C    Elevation  Feet Meters

Relative Humidity  Specific Gravity 

Manufacturer  Aerovent American Coolair Corporation Cincinnati Fan & Ventilator Clarage Fan Company Composite Fan Technology Fan Equipment Company Heat Recovery Systems ILG Industries Div. of American Coolair Schaefer Ventilation Equipment TC Fiber-Aire TC Ventco Twin City Fan & Blower Viron International Corporation No Preferance

Arrangement  Choose an Arrangement 1 2 3 4 4HM 7 8 9 10

Fan RPM        Fan BHP 

Please check any additional options you would like included on the fan:

Access Door      Belt Guard       Coupling      Coupling Guard       Drain   

Inlet Box         Inlet Box Damper         Inlet Vane Damper         Inlet Flange

Outlet Flange        Outlet Damper      Outlet Flex Connection     Outlet Guard 

Shaft Guard       Shaft Seal        Spark Resistant Construction      Split Housing 

Unitary Base       Fixed V-Belt Drive         Adjustable V-Belt Drive        

Vibration Isolators 

Special Coating    Please Specify 

Special Material of Construction

Motor Specifications:

Constant Speed        Variable Speed          VFD       Please Quote a VFD  

High Efficiency        60 Hz Voltages  Choose One 1-115 1-115/230 1-200 1-230 3-200 3-220 3-220/380/440 3-380 3-415 3-440      50 Hz Voltages  Choose One NA 1-110 1-110/220 1-200 1-220 3-200 3-220 3-220/380/440 3-380 3-415 3-440    

Enclosure  Choose One TEFC TEAO ODP EXPL PE Mill and Chem

Additional Information:

Freight Please Select Freight Terms Freight Allowed Freight Not Included Estimate Freight Charges       Provide Shipping Weights 

Special Requirements

You can fax this form to Brookside and Lane directly at 816-561-2087 or e-mail by hitting the submit button below.