Commercial Online Warranty Form Commercial On-Line Warranty Form Commercial purchasers of our products should either complete this on-line warranty form or mail in the warranty form card within 10 days of purchase in order to validate the warranty. Company Name*Primary Contact Name* First Last Federal Tax ID#Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Purchase Date*Purchased From:* First Last Model Purchased*Serial #*Distributor Address Street Address City State / Province / Region ZIP / Postal Code Distributor's Website I learned about Pure Water Distillers from: Internet Search Magazine Relative Friend Radio Webinar Other 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? Dental Medical Laboratory Factory School Institution Bank Government Military Other Primary reason for owning a Pure Water Distiller is... Bad tasting water Tap water may be unhealthy To improve employee relations As part of our employee wellness program Autoclaves Industrial Batteries Turbine Wash Electronics Wash Chemical Mix Other Do you have in-house maintenance staff? Yes No If yes, who is responsible for this distiller? First Last PhoneEmail 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? First Last PhoneEmail Would your employees be interested in units for home use? Yes No If yes, who should we contact? First Last PhoneEmail 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. Captcha
