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Contact Information

Full Name:

Address:

City:

State:

Zip Code:

County:

Home Phone: (ex: XXX-XXX-XXXX)

Work Phone: (ex: XXX-XXX-XXXX)

E-Mail Address:

Water Information

Would you like a Free Water Analysis?
Yes   No

Would you like literature and/or free estimate on Kinetico products?
Yes   No

Do you use bottled water?
Yes   No

Are you a homeowner?
Yes   No

Does your water have an unpleasant smell or taste?
Yes   No

What is your water source?
Well City Community District

Do you presently have a water softener?
Yes   No

If yes, what brand?

Do you presently have a filter or reverse osmosis drinking water system?
Yes   No

If yes, what brand?

How would you rate your water?
Poor Good Fair Excellent

Number of people in home?

What is the best time to reach you?

Any special comments or questions?

How did you hear about Rabb/Kinetico?
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