| Model Number |
|
| Serial Number |
|
| Date Installed |
|
| Installed By |
|
| Voltage Reading |
|
| End User |
|
| What is This Device Protecting? |
|
| Estimated Value of the Equipment Being Protected? |
|
| Estimated 24-Hour Downtime Cost if Equipment is Lost? |
|
| Device Mounted As Close As Possible To Connection Points: |
|
| Lead Conductors Cut As Short As Possible Without Straining or Creating Sharp Bends |
|
| Rate Ease Of Installation |
|
| Other Comments |
|
Proudly Handmade in the USA • Since 1988
1-800-583-4773 
info@maxivolt.com