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Clutch/Brake Combination Application Form

Contact Information

* Contact Name:
* Company:
Address 1:
Address 2:
City:
State:		Zip/Postal Code:
* Phone:
Fax:
* Email:
* Required Fields

Please provide as much information as possible. We will be happy to assist you with questions: 859-291-0849

Specifications

1. Clutch/Brake is needed for:

New Machinery
Retrofit - to replace (Mfg., Model, Etc):

* 2. Clutch/Brake Mounting:

End of Shaft
Shaft Size (specify inches / mm):
Keyway (specify inches / mm):
Thru-Shaft (with reaction/torque arm)
Shaft Size (specify inches / mm):
Keyway (specify inches / mm):
Coupling Two Shafts
Drive Shaft Size (specify inches / mm):
Drive Shaft Keyway (specify inches / mm):
Driven Shaft Size (specify inches / mm):
Driven Shaft Keyway (specify inches / mm):
Nema Frame (C-Face)
Frame Size:

3. Clutch/Brake Configuration: Clutch/Brake will...

Stop & Start the Shaft
Start and Stop the Sprocket(s)

4. Sprocket Requirements:

Single
Double

Chain Size: # of Teeth:

5. Input Source:

Electric Motor
Gas Engine
Diesel Engine

HP: RPM:

* 6. RPM at Clutch:

* 7. Cycle Rate (X per Minute):

* 8. Required Torque
Clutch(specify lb.in / lb.ft / Nm):
Brake(specify lb.in / lb.ft / Nm):

9. Inertia of the Load (specify lb.ft² / kg.m²):

10. Operating Air Pressure Restrictions (if any):
Minimum (PSI): Maximum (PSI):

11. Envelope Restrictions (if any):
Maximum Length (specify inches / mm):
Maximum OD (specify inches / mm):

Additional Information
Please include any special requirements, environmental conditions, etc.