Domestic Dealer Questionnare PERSONAL 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 * ---Sole ProprietorshipPartnerCorporation Purchase order required? * ---YesNoSHIP 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.FilteredDo you presently use/sell water distillation systems? YesNoNever Used or SoldHow did you find out about Waterwise? MagazineInternetFriendTrade ShowRadioDo you currently own a Waterwise product? YesNoWhat 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.