
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 _____________________________________________________________________________