Company:
Address:
Contact Name:
Phone/Email:

Has there been a budget established for surge suppression?    Yes, budget is $    No

How will you be presenting the solution?    In Person    By Phone/Mail    Need Help


Is the facility experiencing power quality problems now?    Often    Sometimes    Seldom

Has the facility experienced loss of equipment?    Recently    In the Past    Never

Has the facility experienced shutdown/restart of equipment?    Recently    In the Past    Never

Has ground integrity been confirmed? (N-G at 0 volts)    Yes    In Planning    No

Is there industrial expansion close to the facility or location?    Recently    Planned    No Plan

Is the facility itself undergoing expansion?    Recently    Planned    No Plan

Does the facility use a generator regularly?    Often    Sometimes    Seldem


What is the facilities geographical location (elevation)?    High    Medium    Low

What is the facilities specific location?    Rural    Suburban    Urban

Of Structures in your locality, is the facility the…    Tallest    Equal Height    Shortest

What is the facility’s location on the utility line?    End    With Others    Dedicated

The equipment to be protected is classified as…    Critical    Important    Expendable

Cost of repairs/replacement of equipment is…    Expensive    Moderate    Inexpensive

Location of the equipment to be protected is…    Main (or Service Entrance)    Distribution    Branch

Description of Problem:

Panel (Ex: MDP, LP1, etc.)	Location (Ex: Service Entrance, Distribution or Branch Panel)	Amperage	System Voltage Code (Choose from list below)	Panel fed from (Ex: Utility, MDP, etc.)	Space or Spare Breakers Available?
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No
					Yes No