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Residential Online Warranty Form

Residential On-Line Warranty Form

Residential 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.

Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Purchase Date*
Purchased From:*
First
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
My tap water comes from:
- City water supply
- Rural water supply
- Well water
I am:
- Male
- Female
Age Group
- 20-35
- 36-50
- 51-75
- 76 & over
Household Annual Income
- $0 to $20K
- $20K to $30K
- $40K to $50K
- $50K to $75K
- $75K to $100K
- $100K+
Maritial Status
- Married
- Single
- Divorced/Widowed
Primary reason for owning a Pure Water Distiller is...
- My tap water tastes bad
- Medical/Dietary reason
- Safety concern
- My tap water is unhealthy
- Healthy lifestyle
- Other
Your Occupation
- Homemaker
- Professional / Tech.
- Retired
- Farmer / Rancher
- Other
We have a daily 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 in learn more about our business opportunity?
- Yes, please send me more information and occasional updates.
I know others who would benefit from owning a distiller.
- Relatives
- Friends
- Other
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Captcha