Name:

Company:

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Fax:

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Input:               Universal 110VAC 220VAC DC

DC Input:   

    #1

    #2

    #3

    #4

    #5

Output Voltage:

Output Current:

Total Output Wattage:

Mechanical Needed:

PCB ATX BOX Desktop Wallmount U-Bracket L-Bracket

Cooling:

Convection Forced Air

I/O Connectors:

Barrier Strip Molex Hard Wire Special

Safety Agency:

Prototype Quantity Needed: 

Date Needed:  

Expected Annual Usage:  

Additional Comments: