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Dealer Location Request Form

To help us find the nearest/most convenient dealer for you, we would like to find out some information about you. Please fill out the following form and we will contact you.

First Name:
*Required
Last Name:
*Required
Address:
*Required
City:
*Required
State/Prov.
*Required
Country:
*Required
ZIP/Postal Code:
Phone #:
*Required
E-Mail
*Required
   
Which Product(s) are you interested in? (click any that apply)
Portables Centrals
If you want information on a specific product, select from the list below
XR-100 Roomaid 2500 HV 4000 HV
2500 3000 AWW-350 AWW-675
6000V Cart 7500 Cart 6000V 6500
Nutri-Tech 6 stage Nutri-Tech 9 stage 8500 10,000

 

What are you looking to buy : *Required
New System(s) or Replacement Filter(s)

Are you comfortable with buying a Water Filter Canada Product online? *Required
yes no

 

The Following is OPTIONAL information:

Do you or anyone in your family suffer from:
Allergies, Asthma, Other Respiratory Problems

Where did you hear about Water Filter Canada?

Is this purchase going to be for: Commercial or Residential use?
If Residential, will it be used in an: Apartment or a House?

 

Thank you,

 

 

 

(the form will send as an e-mail through your default e-mail program, you may need to hit 'send' from there)

 

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Service site for BelKraft All Rights Reserved