North America Dealer Questionnaire

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NORTH AMERICAN DEALER QUESTIONNAIRE

PERSONAL

First Name

Last Name

Address

City

State/Province

Country

Zip/Postal Code

Telephone

Fax

BUSINESS

Business Name

Date Business Started

Your Position

Mail Address

City

State/Province

Country

Zip/Postal Code

Ship to

Attention

Address

Address 2

City

State/Province

Country

Zip/Postal Code

Telephone

Fax

E-mail

Web Site

Business is:

Purchase Order Required?

Best Time To Call

Brief Description of Business

GENERAL

What type of water do you drink?

1	Tap	4	RO
2	Bottled	5	Filtered
3	Distilled

Do you presently use/sell water distillation systems?

1		Yes
2		No
3		Brands
4		Never Used or Sold

How did you find out about Waterwise?

1		Magazine
2		Internet
3		Friend
4		Trade Show
5		Radio
6		Other

Do you currently own a Waterwise product?

1		Yes
2		No

Can you meet a minimum first order of $2500?

What time would you devote to this business?

1		Part-time
2		Full-time
Start Date

What sales territory could you effectively cover?

Why are you interested in and what are your goals related to the water purification business?

I understand that this is not a contract nor does it constitute an agreement toward partnership and/or representation. It is for informational purposes only. I certify the accuracy of the above information.

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