Information Request Form

First Name:                                                                                                               

Last Name:                                                                                               # of Adults                   # of Children

Address:

City:                                                                               State:                            Minnesota residents only.

E-Mail Address: (required for response)

                                                                             

Phone Number:                                                  extension               

The best day to reach me is:                              The best time to reach me is:  

About Me:

                        

My water supply comes from:              

Please mark all that apply:

I have:

                                                                     

                                                                                                  My water has:                        gpg of hardness

                                                                                                                       

                                                                                                                                              ppm of iron

                                                                                                                       

Other Concerns:

                                                            

Thank You!

Dakota Water Treatment of Minnesota, Inc.

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I would like a representative to contact me.

I do not wish for a representative to contact me.

I recently had my water tested

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I am interested in a Water Softener for my home.

I am interested in a Drinking Water System for my home.

I am interested in a UV Air Purifier for my home.

I am interested in a FREE water analysis.

I have Nitrates in my water

I have I have Bacteria in my water

Allergies

Smoke or pet odors in my home

Flu or colds more than 2x a year

Dry, itchy skin

Discolored  laundry

Color to my water

White film on my dishes and glassware

Rust stains on tub, sink or toilets

Bad taste or odor to my water

Black film in toilet tank

Excema or chlorine allergies

I am interested in a DeChlorinator for my home.