Shelter Survey Form 02

ProVisio/Shelter+ Request for Information

Please fill out this form to the best of your ability. A ProVisio/Shelter+ representative will respond to your request as soon as possible. Thank you for your interest in ProVisio and Shelter+.Please note: all items marked with an " * " are required fields.

PART 1. COMPANY INFORMATION

Company/Organization

*

Name

*

Address

*

City

*

State/Province/Region

*

Zip or Region Code

*

Country

*

Telephone/Cell No.

*

Email

*

Company/Organization

Name

Address

City

State/Province/Region

Country

Zip or Region Code

Telephone/Cell No.

Project Manager

PART 2. FOUNDATION OVERVIEW/DESCRIPTION

Foundation: General Description *

PART 3. PROPOSED USAGE

Clinic	Office	Laboratory (Medical)
Laboratory (Scientific)	Telemedicine Unit	Advertising
Military Rugged Deployment	Disaster Recovery	Refiniery Applications
Restaurant	Retail/Novelty	Hotel/Resort
Residential	Commercial

PART 4. CONTAINER GENERAL OVERVIEW

Capacity

Length

Width

Gross Weight

Electrical Systems Requirements (Overview)

Lighting Requirements (Overview)

Primer/Finish Coat

R-Value

PART 5. SYSTEM(s) REQUIREMENTS

ENERGY:

• All modules are supplied with a dedicated electrical distribution panel that provides 15A device with ground fault, overload and electromagnetic interference protection.

• A separate 20A circuit is provided per module for miscellaneous medical equipment.

Electric Capacity

Solar Capacity

BACKUP POWER:

Solar Cell (Backup)

Fuel Cell (Backup)

Generator (Backup)

ACCESS SYSTEMS:

Entry/Access & Pass Through Ante Rooms

Extra Wide French Doors

Ergonomic Threshold Ramps

CCTV/Card Access

Locking Mechanisms

ADDITIONAL SYSTEMS:

Please describe any specific requirements in the ADDITIONAL INFORMATION section below.

Refrigeration Systems

HVAC Systems (HVAC Environmental Control Units)

Bathroom Facilities

Water Source & Backup

Clean Room Facilities

Telecom Wiring

Specialized Equipment

IT Configuration

ADDITIONAL INFORMATION/EQUIPMENT

Thank you for your interest in working with SHELTER+. We will process the information that is sent and contact you as soon as possible. If you are confident that your information is accurate, please click on the SUBMIT button below and your information will be sent to our representatives.