Lift Assist Application Form Step 1 of 10 - Customer Information 10% Quotation Type Budgetary (Project Funding)Firm (Funded Project) Customer Information Company Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Name* First Last Email* Phone* Application Information Please Indicate What Unit of Measures You Intend on Using Within This Form* lb kg in cm fahrenheit celsius Description of Part to be Handled* Please Attach any Drawings of the Part Drop files here or Parts Available for Runoff / Tryout* YesNo Number of Different Parts to be Handled* If Different, are Parts Run In* Batch Random Sequence Dimensions of Part: Maximum Weight* Dimensions of Part: Maximum Height* Dimensions of Part: Maximum Width* Dimensions of Part: Maximum I.D.* Dimensions of Part: Maximum O.D.* Dimensions of Part: Minimum Weight* Dimensions of Part: Minimum Height* Dimensions of Part: Minimum Width* Dimensions of Part: Minimum I.D.* Dimensions of Part: Minimum O.D.* Surface Finish* Wet Oily Dry Hot Class A Fragile Textured Other If Hot Specify Temperature* If Other Explain Description of Current Process/ Sequence of Operation* What is the Justification for Manipulation* Reduce Manpower Ergonomis Safety New Products New Work Cell Other Check All That Apply If Other Explain Comments System Quotation Specifications: Part Pick Up Are There Obstructions Around Part at Pick Up* YesNo If Yes, Specify* Suggested Area For Attaching Device to Part** Areas of Part that Should Not be Touched** Part Orientation at Pick Up** Operator’s Perspective Part Elevation at Pick Up** Dimensions Provide Necessary Sketches Where * Appears Drop files here or Comments System Quotation Specifications: Part Set Down What Part is Being Set Down Into/Onto** Are There Obstructions Around At Set Down?* YesNo If Yes, Specify* Part Orientation at Set Down* Operator’s Perspective Part Elevation at Set Down** Dimensions Provide Necessary Sketches Where * Appears Drop files here or Comments Handling Device Features Style of Handling Device* ClampVacuumProbeHookTrapOther Type of Controls* UP/DWBalElectronic Single or Dual Control* SingleDual Motion of Handling Device* Straight TransferRotateTiltSwivelOperator Degree of Rotate / Tilt / Swivel* Straight TransferRotateTiltSwivelOperator Control of Rotate / Tilt / Swivel* PowerManual Provide Sketches of Rotation and/or Tilt as Viewed by Operator if Rotate or Tilt Motion is Selected Drop files here or Comments Environment Power Source: Air Pressure* N/A60-70 PSI70-80 PSI80-90 PSIOther PSI Power Source: Electrical Supply* N/A115 VACOther If Other Explain Conditions* Hot Cold Corrosive Dusty Clean Room Food/Beverage Medical If Hot or Cold Please Specify Temperature* Elevation Information* Elevation from Floor to Bottom of Header Steel* Can Elevation Drawings be Provided?* YesNo Can Work Area Drawings be Provided?* YesNo Please Attach Drawings Drop files here or Comments Mounting Options Balancer Style* 150 lbs200 lbs350 lbs500 lbs If Other Explain Arm Style* SP SeriesFR Series Comments Additional Requirements Can Rack or Dunnage be Provided?* YesNo Are Detail Drawings Required? (Extra Charge)* YesNo If Yes, Indicate the Desired CAD Format Can Part Drawings be Provided?** YesNo Can Tooling Drawings be Provided?** YesNo Can Videos/Photos be Provided of Area?** YesNo Can Floor Plans be Provided?** YesNo Customer Review Required Prior to Shipment?* YesNo Type of Review if Required* LiveVideo Provide Necessary Sketches Where * Appears Drop files here or If There Is More Than One Pick Up and Set Down Operation Fill Indicate The Additional Information Here Special Requirements Please Indicate Any Special Requirements/Custom Specifications Budget Additional Information Comments File Drop files here or CAPTCHA Phone This field is for validation purposes and should be left unchanged.
