DATE EXIDE/RESTORE CONTACT PHONE EMAIL CELL FAX CUSTOMER NAME * STREET ADDRESS* CITY * STATE/PR* POSTAL CODE* COUNTRY* CONTACT * PHONE EMAIL * DESCRIPTION OF APPLICATION IMPLEMENTATION TIMELINE (check one) 0 to 3 months 3 to 6 months 6 to 9 months 9 to 12 months 12+ months SYSTEM VOLTAGE Nominal * DC Maximum DC Minimum DC TEMPERATURE CONTROLLED Ambient C F Maximum C F Minimum C F Environmentally controlled? Yes No DISCHARGE CYCLE Power in watts * OR Current in amps Desired discharge time in hours in minutes Expected depth of discharge % Expected number of cycles per year * month week day CHARGE CYCLE Power in watts OR Current in amps Desired charge time in hours DESIRED PRODUCT LIFE Time in years End of life capacity % of original capacity AVAILABLE SPACE Length Width Height Inches mm MISCELLANEOUS Stationary / High Vibrations / Weight Restrictions / Other Notes CHARGER NEEDED ? YES NO Manufacturer INVERTER NEEDED ? YES NO Manufacturer COMMUNICATION METHOD CAN SMBus Other Ethernet WIFI Zigbee None

A copy of this application will be emailed back to you for your records.

Restore Energy Systems / Phone 604.525.4114 Ext. 101 / Fax 604.525.4110
www.restoreenergysystems.com