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Capacity

Total load (lbs.) of the unit:

Number of casters under the load:

Divide the total load by the number of casters to get the load (lbs.) per caster:

Will people be on the unit?: Yes No

Will the unit be subject to shock?: Yes No

Will the unit be towed?: Yes No (if yes, what speed?)

Floor Surfaces and Conditions

Type of floor:

Type of condition:

Are floor marks a concern?: Yes No

Is noise a factor?: Yes No

Any unusual environmental conditions?: High Temp Low Temp Dirt / Sand Water
Chemical Other

Special Requirements

Caster height limitations: (inches)

Top plate size: (length) x (width)

Mounting hole spacing: (length) x (width)

Stem mounting required: Yes No
If yes, please specify stem type (i.e. Threaded, Octagon, Grip Ring, Rubber Expandable, etc.)
Dimensions, diameter & length:

Wheel brake required: Yes No

Swivel Lock: Yes No

Sanitary (NSF): Yes No

Any other special requirements:

Your Contact Information

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Company name*:
Address*:
City*:	State: Zip:
Phone*:	Fax:
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