Company Name:

Website:

E-mail Address:

Telephone Number:

Contact person:

Please describe your primary business in detail:

Are you a representative and/or a distributor?

What is the company’s experience in the sales of water treatment products?

What other lines and types of products do you currently sell and for how long? (List Company Name, Product, How Long?)

What geographic areas do you serve and in which you wish to represent our products? (List by region and country)

Please estimate your annual purchases of our products in U.S. dollars

Any additional information you want us to consider