Free Cooler Trial Form
Company Name:
Position:
First Name:
Last Name:
Address:
City:
Province/State:
Country:
Postal/Zip Code:
E-mail:
Telephone #:
Fax #:
Optional Information :
To help us install a free trial that meets your needs, please answer the following:
Your current water supply:
Tap (None)
Bottled Water
Filtration
If Bottle Water: What type of water are you drinking?
Regular Bottle Water
Reverse Osmosis
Distilled
Other (please specify)
Usage per month (if bottles):
Number of coolers:
$$$ per month on water:
Number of Employees:
How did you hear about City Water International?
Please indicate how we should contact you:
E-mail
Telephone
Facsimile
