Retrofit Application Questionaire

Customer Information:

Date:

Contact Name:

Contact Position:

Company Name:

Company Address:

Address (cont.):

City:

State/Province:

Zip/Postal Code:

Country:

Work Phone:

FAX:

E-mail:

Manufacturer & model of existing weighfeeder/belt scale (if applicable):

Manufacturer:

Model:

Product being monitored:

Material:

Capacity:

Application:

Description of the application:

Accuracy Required: % (up to ± 0.25%)

Electrical classification at location:

Installation:

Power Available:

Inputs Required: (check all that apply): 4-20 mA
LVDT
Variable Speed
PID
Load Cells (#):

Outputs Required: (check all that apply): 4-20 mA
PID
Remote totalizer
Relays (#):

Communications: AB Remote I/O
DeviceNet
Profibus-DP
RS232/RS-485 Modbus

Comments/Notes
Please note any special instructions, considerations or requirements:

Customer Information:
Date:
Contact Name:
Contact Position:
Company Name:
Company Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Country:
Work Phone:
FAX:
E-mail:
Manufacturer & model of existing weighfeeder/belt scale (if applicable):
Manufacturer:
Model:
Product being monitored:
Material:
Capacity:
Application:
Description of the application:
Accuracy Required:	% (up to ± 0.25%)
Electrical classification at location:
Installation:
Power Available:
Inputs Required: (check all that apply):	4-20 mA LVDT Variable Speed PID Load Cells (#):
Outputs Required: (check all that apply):	4-20 mA PID Remote totalizer Relays (#):
Communications:	AB Remote I/O DeviceNet Profibus-DP RS232/RS-485 Modbus
Comments/Notes Please note any special instructions, considerations or requirements: