Company name:
First name:
Last name:
Position:
Telephone:
Fax:
E-mail address:
Street address:
City:
State/Province:
Zip/Postal Code:

Check one:
My water supply is chlorinated municipal water
My water supply is from a well and is non-chlorinated

On a scale of 0 to 10, [0 being LOW or GOOD] and [10 HIGH or BAD], how would you rate the following conditions of your water supply:

Water Hardness:                   
Water Clarity:                   
Water Odor:                   
Water Taste:                  
(Well Water) Bacterial Content:    

What is the approximate water pressure in your home?
(in pounds per square inch [psi]?)                           

Do you have any other comments about your water supply?