Name
Company
Title
Address
City
State

You prefer: (pick on of the following)
   Fixed Rate Monthly Contract          Pay for chemicals based on usage

You currently receive service: (pick on of the following)
   Monthly          Semi-Monthly       Weekly        Other

Your current chemical provider transports chemicals (pick on 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: