GENERAL PRODUCT INFORMATION

Type of Equipment (Equipment Description): *

Model Number(s):

Markets of Sale (USA, Canada, Europe, Japan, Australia, others):

Usage:
Commercial Household Industrial
Location:
Dry Damp Wet
Sources:
Electrical Pneumatic Gas

Hazardous Location? Yes No

Intentional Radiator? Yes No

Type of Product:

Change Made (if product is Manufacturer Design Change):

Dimensions (specify units - cm, in, kg, lb):

Width: Length:

Height: Weight:

Approximate Setup Time:

Nominal Voltages:

Frequency: (Hz)

Amps:

Phase: Single Three

Services:

Gas:
Propane (BTU)

Natural   (BTU)

Other      (BTU)
Air:          (PSI)
Water:    (GPM)

PLEASE SUBMIT WITH ORDER
The following information is required to start the evaluation:

Schematic Diagram
Wiring Block Diagram
Block Diagram
Isolation Diagram
Simplified Installation/Operation Instructions
Brochure/Product Literature

ITE Equipment Information (if applicable):

Does equipment have telecommunications capability? Yes No

Does equipment connect to outside plant (OSP)? Yes No

Does equipment generate ring voltage? Yes No

Does equipment receive ring voltage? Yes No

Medical Equipment Information (if applicable):

Is it life support equipment? Yes No

Does it have patient connections? Yes No

Is it radiological equipment? Yes No

Does it control or measure physiological parameters? Yes No

Is it used to cauterize living biological tissue? Yes No

Laser Equipment Information (if applicable):

What type(s) of lasers?

Is laser pulsed during use or steady state?
Pulsed Steady State

What is the laser peak power?

What is the wavelength?

What is the class?

PRODUCT INFORMATION FOR EMC TESTS

Please list all operating frequencies used within the device:

Mode(s) of Operation:
List all modes of operation in which the EUT needs to be operated,
in order to be fully exercise all components/systems.

I/O Cables:

Function Type Of Shield Length Connectors
1
2
3
4
5
6
7
8

Support Equipment:
Intertek recommends our customers provide all support equipment
necessary to fully operate the EUT. For all support equipment provided by
Intertek list appropriate equipment below, additional charges may
apply for all equipment not part of Intertek standard inventory of
support equipment.

Description Manufacturer Model No.
1
2
3
4
5
6
7
8

Monitoring of the EUT:
Please provide instructions below on how to observe the EUT
to verify proper operation in all modes.

Please provide any special instructions or requirements for
your project: