Manifold Selection Worksheet

By supplying the information requested below, Western Enterprises will be able to assist you in the selection of the proper manifold for your application.  Complete and click the send button or fax to #440-835-8283, attention Manifold Sales.

Contact Person: Date: 
Street Address:  City: 
State:  Zip: 
Email Address: Country: 
Telephone:  Fax: 

Please answer the questions below completely and accurately

1) Type of Gas (include percentages if using a mixture)

        Liquid:                            Gas:

2) Application: (Please describe in detail)

Industrial: Medical: Specialty Gas:
3) CGA connection as supplied:
4) Type of Manifold:
    4a) Open/Cabinet:  4b) Automatic: 
5) Total number of cylinders required: 
    5a) Single Bank: 5b)Dual Bank:
6) Delivery Pressure Required (line):
    6a) Flow Rate Required:
7) Header Configuration Required: 

   (If L or U-Shaped is desired, a detailed sketch must be submitted with this form.)


Staggered 


Straight 


Vertical Crossover

Crossover 



8) Accessories Required:    
9) Remote Alarms Required: 
10) Any additional information that would be pertinent to the recommendation:
11) Do you need a copy of the current manifold catalog? YES     |    NO