Response-O-Matic Form

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Your comments are appreciated!

Just complete this form. Click on Submit when ready to send.

NAME:
ORGANIZATION:
MAILING ADDRESS:
CITY:
PROVINCE:
POSTAL CODE:
PHONE NUMBER:
FAX:
E-MAIL:

HOW WOULD YOU LIKE US TO RESPOND?
MAIL
PHONE
FAX
E-MAIL

WHAT TYPE OF TREATMENT EQUIPMENT WOULD YOU LIKE QUOTED?
REVERSE OSMOSIS
ULTRAVIOLET LIGHT
SOFTENER
AUTOMATIC FILTER
CARTRIDGE FILTER
OTHER
DON'T KNOW

ARE YOU LOOKING TO REPLACE AN EXISTING UNIT?

YES
NO

GIVE A BRIEF DESCRIPTION OF YOUR WATER QUALITY ISSUES

WHAT IS YOUR SOURCE OF WATER?
MUNICIPAL
PRIVATE WELL
SURFACE/LAKE

HOW MANY PEOPLE ARE IN THE HOUSEHOLD?

IF YOUR WATER HAS BEEN TESTED, PLEASE ENTER THE VALUES

HARDNESS: IN GRAINS PER GALLON
IRON:
PH:
TDS:

WHAT TYPE OF TREATMENT EQUIPMENT DO YOU PRESENTLY HAVE?

FOR WELL OWNERS ONLY

WHAT TYPE OF PUMP IS SUPPLYING YOUR HOUSE WITH WATER?
SUBMERSIBLE
JET
PISTON PUMP
DON'T KNOW

Any comments?

NAME:
ORGANIZATION:
MAILING ADDRESS:
CITY:
PROVINCE:
POSTAL CODE:
PHONE NUMBER:
FAX:
E-MAIL: