Date:                                                 Authorized by: 

Company Name:    Address:

 Phone:   Fax No.  Email Address:

Please list below your requirements and we will reply promptly:

Capacity:   Min:   Max:      HP or #/HR:

Boiler Operating Pressure:                  SuperHeat: 

Fuel: Check the box that applies: Natural Gas   Oil    Coal    Wood   LP Gas    Other

Manufacturer Preference:     Age Limits: 

Condition:    Check one  Ready to Operate, No repairs required                                        

                                           Needs minor repairs, clean, paint, adjust                             

                                           Needs major repairs, retube, refrac, controls                        

                                           Specify      

When Needed:    Now  or  Future:  Please enter date if needed in the future: 

Your cost limits: 

Voltage:                           Insurance:                Phase: 

   Enter other pertinent data in the box below: