Prospective Dealer Form

In consideration of your interest in becoming a sales representative/distributor for Alpha Water Systems Inc,
we would like to know more about you and your company.

All information provided will be kept strictly confidential.

To receive the appropriate dealer information packet...
Please fill out this form completely

You may also print this form, fill out completely and fax to 973-293-8056
or mail to the address at the bottom of this page.

Your FULL E-mail Address is required to send this form

Personal Information...

First, Last Name





Zip Code

Home Telephone


Your Home Own Rent

Years at Current Address

Business Information:

Name of Business

Your Position

How Long with this Company

Tax Exempt Yes No

Taxpayer ID# (FEIN or SSN)

Occupational License YesNo

Description of Business

How Many Years in Business

Business Phone/Fax Numbers:



Business Postal Mailing Address:





Zip Code

Ship To Address (If Different than Mailing Address)

General Information Survey...

How did you find out about Alpha Water Systems Inc?


What educational or business background do you have in water treatment/purification?

Additional Information...

Please enter any additional information that you would like us to consider...

I understand that this form is not a contract nor does it construe any agreement towards
partnerships and or representation. The information will be completely checked.

I certify the accuracy and the validity of the above information YESNO

Applicant's Full Name

Application Date

Thank you for providing us with this information...
It will be kept strictly confidential

You may also print this form,
and fax to: 973-293-8056

or mail to:

Alpha Water Systems Inc

P.O. BOX 1210
MONTAGUE, N.J. 07827

Phone: 973-293-7856

Copyright © 1997-2011  Alpha Water Systems Inc.