MCGS011A

Printed in U.S.A.

Reprinted 4/2002

To facilitate processing your request, please fax this page to our Product Specialists.

From ________________________________________________________

Company_____________________________________________________

Address______________________________________________________

Phone _____________________

Fax _______________________

To: Marketing Dept.

Texas Instruments

Attleboro, MA 02703

Phone: (508) 236-3192

(508) 236-1894

(508) 236-2349

Fax:

The following information will help us determine the correct thermostat design for your application. You

may refer to the charts on pages 2 and 3 for assistance.

Request: Pricing _____________________________

Application Assistance _________________________

Description of Application ______________________________________________________________________

Estimated Annual Usage _______________________________________________________________________

Automatic Reset_______ MR________ MR-TF________ SPST________ SPDT________ DPST________

Open Temperature ____________________________

Maximum Tolerance ___________________________

Close Temperature ___________________________

Maximum Tolersnce ___________________________

Temperature Exposures: Maximum __________________________ Minimum _________________________

Location With Respect to Heat Source ___________________________________________________________

Temperature Transfer Medium (air, metal surface, etc.)_____________________________________________

Type of Heat Source:

Convection _____________

Conduction ____________

Radiation ____________

Electrical Requirements: __________________ Amps @ _________________ Volts; AC or DC ___________

Resistive ___________________

Inductive ___________________*

Capacitive ___________________*

Tungsten Filament __________________ Milliamp _________________ Pilot Duty _________________

*If inductive or capacitive, indicate power factor __________________________________________________

(If available, please send copy of electrical / plumbing diagram).

Switch Termination (type and angle)_____________________________________________________________

Flange (type and angle of rotation) ______________________________________________________________

Enclosed or Exposed Disc ______________________________________________________________________

Environment (dust, lint, chemical fumes, etc.) ____________________________________________________

_____________________________________________________________________________________________

Agency Approvals _____________________________________________________________________________