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1. What are your contaminants of concern (Check all that apply)
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Other:
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2. Are you interested in improving your (check all that apply)
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Other:
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3. What is your water source?(Check all that apply)
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4. How many people are in your household?
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5. If we are not familiar with the characteristics of your source water, we may request you to send us a sample of your water. If this is the case, would you like us to send you a sample bottle? There is no charge for this screening test, other than the return postage.
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6. Other Comments or Questions:
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7. How did you find out about Custom Pure?
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Enter Verification Number:
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