Company:

Street Address:

City:

State:

Zip:

Contact Person:

Title:

Tel:

Fax:

Email:

Application Details:

Brief Description:

Battery is used for:Back upMain power source

Electrical Requirements:

Operating Voltage:

Constant Current:

Constant Current=

Pulse Current:

lp=

Duration:

T=

Every:

T=

Pulse Load Profile: Please enclose a drawing if needed
Qualification Tests: Please enclose specifications

Expected Operating Life:

Storage of battery before use:

Environmental Requirements:

Storage Temperature – Please specify percentage(%) of time per temperature. Make sure it sums to 100%

Max Temp (ºC)

Average Temp (ºC)

Min Temp (ºC)

% of time at Max

% of time at Average

% of time at Min

Operating Temperature:

Max Temp (ºC)

Average Temp (ºC)

Min Temp (ºC)

% of time at Max

% of time at Average

% of time at Min

Special conditions of humidity, shock, vibration etc.’:
Please enclose specifications or list in the remarks below

Size and Dimensions of cell:

(Please attach a drawing if a battery pack is required)

Preferred Cell Size:

Max. Space Available (mm):

Estimated Annual Requirement:

1st year

2nd year

3rd year

Qty for First delivery

Expected during (Month)

Expected during (Year)

Alternative Battery:

Remarks:

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