Name:

Business Name:

Address:

City:

State: Zip:

Phone:

Fax:

Cell Phone:

Email:

Do you use bottled water? : yes no

Are you a homewoner ? : yes no

Do you have a rotten egg or chlorine smell/taste? : yes no

Where does you water come from? : city well community

Do you presently have a water softener? yes no

If yes, which brand?

Would you like iterature or a free estimate on Kinetico systems ? yes no

How would you rate your water ? poor fair good excellent

How many people in your home? 1 2 3 4 5 or greater

What is the best time to reach you ?

Message: