Request For Quote Submittal Form

*Please be sure to complete all information marked with * so we may provide a timely and complete quotation. If requested, Birk will have an application engineer call you to help with your thermal systems requirements.

Contact Person*
Company Name*
Address*
City*
State*
Zip*
Telephone*
Email*
Please have an application engineer call Yes No
How did you hear about Birk? Search Engine Trade Show Referral Other
Heater Information
Upload your own drawing:
Type of Heater* Silicone Rubber Kapton Butyl Other

Birk Manufacturing Preliminary Heater Design A B C D
Size:*
Qty:*
Watts*
Volts*

Lead Locations A B C D E F
Lead Length*
Lead Type* Teflon SR Other
Application Info
Pressure Sensitive Adhesive
Operating Temp*
Temperature Controlled*
Control Type
Thermistor:	Yes No
Thermocouple:	Yes No
T-Stat:	Yes No Set Point: °C
Ambient Conditions
When will delivery be required?*
Special Features

14 Capitol Drive, East Lyme, CT 06333 | Phone 1-800-531-2070