Company Name:   Tel#:
Address:   Fax#:
City:   State:   Zip:   Country:
Contact:   Title:   e-mail:

Conveyor ID# or Conveyor Location:

Belt Mfg. Name and Catalog or Belt Designation Code:

Belt Data
Belt Speed ft/minute       Width inches       Conveyor Length ft.      Thickness inches
Material Construction   Coating, if any
Flat    Ribbed    Tracking Problems?  Yes No    Travel Both Directions?  Yes No

Drive Pulley
Diameter inches          Flat    Crowned    Ribbed    Lagged

Return Idlers
Spacing feet         Size inches

Method of Joining
Vulcanized    Fastener Type    Protrusion (Height) Above Belt inches

Type of Material to be Removed

Air Temperature                  Average Degrees ºF             Maximum Degrees ºF

Carryback Temperature      Average Degrees ºF             Maximum Degrees ºF

Check those conditions which best describe the Carryback material
Powder      Light      Medium      Heavy      Dry      Greasy
Semi-Moist      Tacky-Moist      Moist      Wet

Standing at the Tail looking at the Head Pulley,
indicate Drive Side for Conveyor Motor                 Left Side   Right Side

Motor Specifications if other than TEFC 220/440 Volt with a Service Factor of 1.15