Commercial Online Warranty Form

Company Name*

Primary Contact Name*

FirstLast

Federal Tax ID#

Address*

Street AddressCityState / Province / RegionZIP / Postal CodeCountry

Phone*

Email*

Purchase Date*

Purchased From:*

FirstLast

Model Purchased*

Serial #*

Distributor Address

Street AddressCityState / Province / RegionZIP / Postal Code

Distributor's Website

I learned about Pure Water Distillers from:

Our tap water comes from:

City water supply
Rural water supply
Well water

For what purpose will this distiller be used?

Drinking water
Non-drinking water
Both

What type of business is this?

Primary reason for owning a Pure Water Distiller is...

Do you have in-house maintenance staff?

Yes
No

If yes, who is responsible for this distiller?

FirstLast

Phone

Email

Does your company have other locations?

Yes
No

Do any of these locations have a Pure Water Distiller?

Yes
No
Don't know

Would any of these locations be interested in a Pure Water Distiller?

Yes
No

If yes, who should we contact?

FirstLast

Phone

Email

Would your employees be interested in units for home use?

Yes
No

If yes, who should we contact?

FirstLast

Phone

Email

We have a blog called www.Watercology.com in which we educate and inspire people to care about the quality of water they put into their body. Do you want to be registered for free?

Yes, sign me up for free!

Are you interested to learn more about our business opportunity?

Yes, send me more information and occassional updates.

Commercial Online Warranty Form

Commercial On-Line Warranty Form

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