Customer Name Job Address Contact Name __________________________ __________________________ __________________________ Car Station For Car no's: ______________________ Total quantity required Main Car Station Auxiliary Car Station Pushbuttons (LED light up) Tamper Resistant Plastic None Door Open Door Open Front S button Door Hold Door Close Door Close Front Up/Down Taxi Alarm Door Open Rear Pass Call Door Close Rear Other _______________________ Car Station Type Applied faceplate Key and Toggle Switches Sub-Plate only Full Swing Return Cab Panel* Key Switches (J200) In locked service cabinet Material / Finish OR Toggle Switches Light Access Card Reader Override Fan Attendant Service Code Blue (includes jewel) Access/Off/Inspection Stainless Steel #4 Brush Finish Independent Service Photoeye Muntz #8 Mirror Finish Inspection Service Mass. EMT (includes disappearing sign and buzzer) __________ Other: Other: ______________ Motor Generator (MG) Floor Lockout’s; Total Qty: None Mount on faceplate Hospital Service (includes disappearing sign) ________ Other _________________________ Floors & Stops Total No.of Stops: Emergency Stop Front Floors (quan): Rear Floors (quan): Push - Pull Switch Key Switch Call Acknow Up / Down Emergency light Other: None Floor Markings Indicator Jewels Braille Plates Standard Other: ____________________ None Cover Size Digital P.I. Segmented Display 2" Provision only None _____________" H X _____________" W 1" Engraving Emergency Lighting Emergency light w/test Test only Motor Generator (MG) _________ None No Smoking Wording City Id Phase II Fire Service Instructions Capacity Certificate on file … No Smoking Symbol Elevator Number Phone Instructions Other ________________________ Fire Service National Code; Year New York None Options _____________ Other: _________________ (Includes keyswitch, call cancel button, jewel and buzzer) Hands-Free Telephone / Intercom Floor Passing Signal Certificate Frame Cover Locks Nudging Buzzer Phone Jack Light Dimmer Switch 110 VAC GFI Outlet Telephone Cabinet (Phone by Others) Provision only for card reader Voice Annunciator Other ____________ EMS hands free phone-supplied by Monitor* *(Includes call button and call acknow jewel) Wiring Provisions only for intercom,phone-supplied by customer Other : ________________________ None Standard Prewiring No Wiring Custom Prewiring; Indicate Below Other Than Above, Indicate Below *Per Monitor Standard Manufacture / Features 125 RICEFIELD LANE FORM NO MC-02S-2 HAUPPAUGE, NY 11788 (631) 543-4334 A HALMA GROUP COMPANY FAX (631) 543-4372