Your System, Your Way ©2013-2014 SureFire Ag Systems www.SureFireAg.com

End Customer: ______________________________ Customer Contact: ___________________________ Address: ___________________________________ City, State: __________________________________ Phone: _____________________________________ E-mail: _____________________________________ Fax: ___________________ __________________

Equipment make, model, year: _________________ Number of rows: ____________________________ Row Spacing: _______________________________ Min Speed: Max Speed: __________

Product being applied: ________________________ Min GPA: ____________ Max GPA: ____________ Would you like electric section valves? Yes No If yes, how many sections?: ____________________ Existing placement method at the row? Yes No If so, what kind? _____________________________ If not, what method is preferred? _______________ Are there existing tanks for this application? Yes No If yes, how many and what size? ________________ Where are the tanks mounted? _________________ If no, what size do you prefer? __________________ Where would you like tanks mounted? ___________________________________________ Need plumbing from the tank to the pump? Yes No _

Dealership Name: ____________________________ Dealership City, State: ________________________ Salesperson Name: ___________________________ Salesperson E-mail: ___________________________ Salesperson Phone: __________________________ Salesperson Fax: _____________________________ What is the best way to contact you? Phone E-mail Fax

Is there an existing controller? Yes No If so, make and model: ________________________ (If no existing controller, A SureFire controller will be quoted.)

What other applications will this controller be used for? _______________________________________

Product being applied: ________________________ Min GPA: ____________ Max GPA: ____________ Would you like electric section valves? Yes No If yes, how many sections?: ____________________ Existing placement method at the row? Yes No If so, what kind? _____________________________ If not, what method is pr _______________ Are there existing tanks for this application? Yes No If yes, how many and what size? ________________ Where are the tanks mounted? _________________ If no, what size do you prefer? __________________ Where would you like tanks mounted? ___________________________________________ Need plumbing from the tank to the pump? Yes No Please return this form to SureFire Ag Email: sales@surefireag.com Fax: 785-626-361 Phone: 866-626-3670 9904 Hwy 25 Atwood, KS 67730

Contact Information

Equipment Information

Product 1 Information Product 2 Informatio

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Placement Method

Placement Method

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Fax: If yes how many sections_2: If yes how many and what size_2: Where are the tanks mounted_2: If no what size do you prefer: If no what size do you prefer_2: Notes 1: Existing controller Y-N: OffBest contact: OffSection Valve 1: OffSection Valve 2: OffExisting Placement 1: OffExisting Placement 2: OffExisting Tanks 1: OffExisting Tanks 2: OffNeed plumbing 1: OffSubmit: Print Form: If so, what kind 1: [ ]If so, what kind 2: [ ]If not, what method 1: [ ]If not, what method 2: [ ]Where would you like tanks 2: Where would you like tanks 1: End Customer: Customer Contact: Address: City State: Phone: Email: If so make and model: Other Applications: Equipment make model year: Number of rows: Row Spacing: Min Speed: Max Speed: Product being applied_2: Min GPA_2: Max GPA_2: If yes how many and what size: Where are the tanks mounted: Min GPA 1: Max GPA 1: If yes how many sections 1: Product being applied 1: Dealership Name: Dealership City State: Salesperson Name: Salesperson Email: Salesperson Phone: Salesperson Fax: Need plumbing 2: Off