1.	Do you wish to receive a FREE introductory subscription to Water Technology®?

Yes     No

First Name:
Last Name:
Job Title:
	(Ex: Director, Test Lead, Project Manager, etc.)
Company:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Suite/Dept:
City:
State/Province:	Select for USA or Canada Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory   American Samoa Guam Marshall Islands Micronesia (Federated States of) Palau Puerto Rico U.S. Minor Outlying Islands U.S. Virgin Islands Northern Mariana Islands Armed Forces Americas AA Armed Forces Middle East, Europe, Canada AE Armed Forces Pacific AP   Other
Zip Code/Postal Code:
Country:	Select Country USA CANADA OTHER
	(Note: If your country is not listed above, distribution is not currently available at your location.)
Email Address:
	(Note: Valid email address is required or you could be disqualified.)
Phone:
Fax:

What is the approximate number of employees in your company? (select only one)

Select Number of Employees Less than 50 50-99 100-499 500-999 1,000-4,999 5,000-9,999 Greater than 10,000

Yes, please auto-fill my contact information for other publication qualification forms.

2.	Do you wish to receive a FREE email subscription to WaterTech e-News Daily™ service?

Yes     No

3.	Primary Business Activity: (select only one)

Individuals involved in Selling Point-of-Use Water Treatment to End Users:	Municipality/Small System
Dealers/Retailers/Contractors	Well Drilling/Water Systems/Pump Contractor
Distributors	Manufacturers/Suppliers
Bottled Water Dealers	Manufacturers' Representatives
Distributors/Wholesalers of Point-of-Use Water Treatment	Government/Educational Institution
Plumbing/Heating/Air Conditioning Wholesalers	Other (please specify)
Specifying Engineer/Water Testing Laboratory/Consultants

4.	Secondary Business Activity: (select only one)

Individuals involved in Selling Point-of-Use Water Treatment to End Users:	Municipality/Small System
Dealers/Retailers/Contractors	Well Drilling/Water Systems/Pump Contractor
Distributors	Manufacturers/Suppliers
Bottled Water Dealers	Manufacturers' Representatives
Distributors/Wholesalers of Point-of-Use Water Treatment	Government/Educational Institution
Plumbing/Heating/Air Conditioning Wholesalers	Other (please specify)
Specifying Engineer/Water Testing Laboratory/Consultants

5.	Job Function: (select only one)

Executive Management	Marketing/Sales
Service	Advertising/Promotion
Engineering	Other (please specify)
Purchasing Department

6.	Purchasing Authority? (select only one)

Sole Purchasing Decision Maker	Approve Purchases
Specify/Recommend Purchases	Not Involved

7.	Number of Locations: (select only one)

4 or more     2 - 3     1

8.	Annual Purchases: (select only one)

Over $500,000     $100,000 - $500,000     Less than $100,000

9.	Our circulation is audited by an independent company that ensures our circulation figures are accurate. To verify your subscription, auditors must know the day of month you were born.

Select day of month 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Would you like to receive EMAIL notices of other print or online publications, and other relevant offers from TradePub.com?

Yes     No

Would you like to receive relevant information from TradePub.com on behalf of third party businesses/organizations?

Yes     No

Request your free White Paper: Fresh Business Practices for Food & Beverage to Meet Today's Top 3 Issues. Are you a mid-sized food or beverage supplier struggling to keep your head above water? Download this white paper for ideas to keep you afloat. Note: Offer Valid in the United States Only.

4 FREE Trial ISSUES OFFER OF The Economist! Insights on the world, weekly. The Economist is a global weekly magazine written and edited for readers who share an uncommon interest in being well and broadly informed. With objective authority, clarity and wit, The Economist presents well-considered analysis of the world's business, political, scientific, technological and cultural affairs and the connections between them. Subscribe to The Economist today and you'll get 4 RISK-FREE issues as a free trial. If you wish to continue your subscription, you'll receive 20 additional issues - 24 in all for just $2.49 an issue (total of $59.76). That's 58% off the cover price. If you decide The Economist is not for you, write 'cancel' on the bill, return it and owe nothing. Note: Offer Valid in the United States Only.

YOUR EMAIL IS CAPABLE OF SO MUCH MORE! Act now for your Free Trial - OnLetterhead turns your email from "white" to "wow". Plugs into your existing email program & includes links to your site, specials, & more. Custom email templates! 1,000's of customers. Inexpensive & effective! Email newsletters also available. Free trial today. Business use only. Note: Offer Valid in the United States Only.

Discover how to find new customers online. Spot Runner brings you new prospects with Online Advertising. We put your business on major search engines like Google, Yahoo, and create you a free video for sites like YouTube! Click to learn more about Spot Runner's Online Advertising solution today! Note: Offer Valid in the United States Only.