Merkle-Korff Industries
25 NorthWest Point Blvd
Suite 900
Elk Grove Village, IL 60007
Tel: 847.439.3760  
Fax: 847.439.3963
General Email: sales@merkle-korff.com
Customer Service Email: cserv@merkle-korff.com

Please complete the form below. Please note: Items marked with an asterisk (*) are required information.
Company*:
Contact*:
Address*:
City*:	State*:
Country:	Zip*:
Part or Drawing Number:
Estimated Annual Usage:
Phone*:
Fax:
Email*:
APPLICATION:
Customer Application
What mechanism is the motor driving in the application?
New Existing
If existing, who is current supplier?
Is unit available for test? Yes No
Are there any problems or concerns with the existing supplier’s motor?
Performance Requirements:
Rated Voltage
Voltage Range
Frequency Hz:	50 60 50/60
Output Torque Est. by
Start Torque
Run Torque
RPM at No Load
RPM at Load
Will gearmotor be stalled?	Yes No
Environment:
Ambient Temp.
Humidity Level
Other
Full Enclosure
Degree of Ventilation
Corrosives
Anything else we should know about the location of our motor in the application?
Duty Cycle/ Life:
<25 25% 50% 75% Continuous Other
Define other
Standard Duty Cycle (Select one)	On Off
Most Demanding	On Off
Minimum Life Required (note: both required)	in cycle in hours
For Reversing Applications, what is minimum time off between reversals?
Braking Requirements:
Is a brake required?	Yes No
Allowable overrun in degrees
Will brake hold a load?	Yes No
If so, how much?	lbs
Overhung Load?	Yes No
How much?	lbs
Distance from mounting surface
Axial Thrust Load:	Yes No
How much?	lbs
Push In Pull Out Both
Output Shaft Requirements:
Shaft OD
Direction of rotation	CW CCW
	Viewed from: Cover side Motor side
Shaft Detail Flat Tongue Woodruff Key Hole Keyway Slot
Extension from mounting surface	Cover side Motor side
Agency Requirements:	UL CSA CE Other
If other, please list
Sound/ Vibration Requirements:
Method of Test
Gear Box Selection:
Do you require a particular Merkle-Korff style gearbox or may we select?
Mounting Position (Select one)	Indicate orientation in your application as shown below:
A B C D E F