Domestic Dealer Questionnaire

PERSONAL
First and Last Name *

Email *

Telephone Number *

Address *

City *

Zip Code *

BUSINESS
Business Name *

Date Business Started *

Your Position *

Business Telephone Number *

Address *

City *

Zip Code *

Website *

Business is *
—Please choose an option—Sole ProprietorshipPartnerCorporation

Purchase order required? *
—Please choose an option—YesNo

SHIP TO
Attention *

Address *

Address 2

City *

State/Province *

Country *

Zip/Postal Code *

Best time to call *

Best description of business *

GENERAL

What type of water do you drink?

TapBottledDistilledR.O.Filtered

Do you presently use/sell water distillation systems?

YesNoNever Used or Sold

How did you find out about Waterwise?

MagazineInternetFriendTrade ShowRadio

Do you currently own a Waterwise product?

YesNo

What time would you devote to this business?

Full-timePart-time

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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