Fill out this form and submit it to us. The "Required Fields*" must be filled in or the form will not be received by us. We will contact you shortly to confirm your needs.
Required Fields *

Customer Information
Company Name *
Date *
Project Name
City *
State / Province *
Zip / Postal Code
First Name *
Last Name *
Telephone Number *
E-Mail Address *

Application Information - General
Briefly describe your application *

Product Deliverables
Estimated Annual Usage: *
Prototype Units Needed by:
Quantity of Prototype Units:
Production Units Needed by:
Quantity of Production Units:
Battery Chemistry (Rechargeable):
Pack Cell Configuration:
Cells in Series
Other (Series)
Cells in Parallel
Other (Parallel)
Pack Enclosure Type
Pack Dimensions (Inches):
Pack Dimensions Entered Are

warningNote: These dimensions represent the working area of the pack that Custom Power can design to. This total volume includes the cells, circuit board(s), insulators, shrink wrap and wiring as a minimum. Allow for adequate space in your device side battery compartment design to ensure proper fit.

Pack Parameters:
Voltage (Nom.):
Capacity (Nom.):
Operating Temperatures:
Temperature (Minimum - Celsius):
Temperature (Maximum - Celsius):
Pack Options (Select all that apply):
If a fuel gauge is required, indicate form:
Charger Parameters:
Discharge Parameters:
Continuous Current (A):
Expected Run Time (minutes):
Peak Current (A):
Peak Current Duration (secs):
Pack Termination:

Application Information - Regulatory
Required Regulatory / Certification Tests: