Customer Request Form

Fields marked with * are required.

	Company Name:
	Position:
	First Name: *
	Last Name: *
	Address:
	City:
	Province/State:
	Country:
	Postal/Zip Code:
	E-mail: *
	Telephone #: *
	Fax #:

	You are a:
	Current Customer
	Prospective Customer
	Other (please specify)
	Your current water supply:
	Tap (None)
	Bottled Water
	Carbon Filtration
	Reverse Osmosis
	Distilled
	Ozonated
	Other (please specify)

	Usage per month (if bottles):
	$$$ per month on water:
	Number of Employees:

	How did you hear about Hyundai Water and Air?
	Please indicate how we should contact you:
	E-mail   Telephone   Facsimile