Name
Company
Title
Address
City
State
You prefer:	(pick one of the following)
	Fixed Rate Monthly Contract
	Pay for chemicals based on usage
You currently receive service:	(pick one of the following)
	Montly
	Semi-Monthly
	Weekly
	Other
Your current chemical provider transports chemicals	(pick one of the following)
	to loading dock
	to service site
	to service site and puts on line
	to service site, puts on line, and disposes of chemicals
You are concerned with Total Operating Costs Including	(pick all that apply)
	Total Utility Cost for Plant/Facility
	Utility Cost for Individual Systems (ie.boilers, chillers, towers, condensers)
	to service site and puts on line
	to service site, puts on line, and disposes of chemicals
Comments: