Please print out this form, fill it out and send it to us using the address or fax number at the bottom of
the page.

Plant:_________________________________________________________________

Address:______________________________________________________________

City_______________________________ State:_______

Zip:____________ Phone:_____________________

Contact:______________________________________________________________

Problem Metals
Smallest Size Metal to be detected:_________in. X _________in. X_________in.

Metal Type(s):____________________________________________________________________________

Processed Materials
Materials to be processed:_________________________________________________________

Contain Iron: Yes_____ No_____ If yes, what type?________________________________ %iron _______

General Facility Information
Equipment to be Protected:___________________________________________________________________

Power voltage available: 115 VAC_____ 220 VAC_____ Other_____________________________________

Power Phase: Single_____ Three phase_____

Power Frequency: 50Hz_____ 60Hz_____

Is power regulated? Yes_____ No_____

Will Metal Detector output be routed to a Central Computer Control? Yes_____ No_____

Conveyor Support Frame: Steel______ Wood_____ Other__________________

Vibrating Conveyor

Conveyor Speed_______FPM, Conveyor inside width - Bottom:________ Top:________

Conveyor inside height (vertical)________

Normal Burden Depth:________ Maximum Burden Depth:________

Metal Free Conveyor Section

Existing____ Planned____

Wood______ Fiberglass______ Other______________________

Length____________ Thickness____________ I.D.____________

Please include cross section drawing/sketch of conveyor when ordering a custom built fiberglass
conveyor section from RENS Metal Detectors, A Division of Lacey-Harmer Co.

Metal Free Conveyor Section required for all metal detectors. Length required dependent on size
and type of metal detector search coil.

Use Space below to describe your operation if different from above and/or to give us any other
pertinent information.

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