1. What are your contaminants of concern (Check all that apply)
2. Are you interested in improving your (check all that apply)
3. What is your water source?(Check all that apply)
4. How many people are in your household?
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.
6. Other Comments or Questions:
7. How did you find out about Custom Pure?
Enter Verification Number: